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ALISON - P - HENGEKA - Proposal
ALISON - P - HENGEKA - Proposal
(MCHAS)
Contact
Phone; +255764918177
Email; ntivyironkahengeka@gmail.com.
1
ACKNOLWLEDGEMENT
First of all, I would like to take this opportunity to give thanks to almighty god for giving me a
life and protections throughout my studies. I solely express my gratefully to my research
supervisor madam Mkola also tutor of leadership and management in health who has been
extremely helpful instructor throughout the whole period of study.
This work is result of different collective’s resources otherwise it could have been difficult to be
done without that effort. Also thanks a principle of Mbeya college of health and allied sciences
and academic officer, furthermore a head department of clinical medicine for their guidance and
emphasis me in every aspect of study to whole period of being available at school. Special
thanks going to my parents and other sponsor who help me economically and make lives well
during a whole time of field work.
i
LIST OF ABBREVIATIONS
ANT –Antenatal Clinic
DEFINITION OF TERMS
Caesarean section; is the procedure of delivering the baby by making surgical incisions in the
Caesarean section rate; is the number of caesarean deliveries over the total number of live
births within a period of time, and is usually expressed as a percentage (betrán et al., 2007).
Elective caesarean section; is the type of cs where the decision to carry out the procedure has
been taken during the pregnancy before labor has started (michaluk, 2011).
Emergency caesarean section; is the type of cs carried out when adverse conditions develop
during pregnancy or labor which indicates need for emergency/urgent caesarean (oguta, 2015).
ii
Parity; the number of born children delivered by one woman (ukeme, 2014).
Gravida; the number of the pregnancy that the woman is in (ukeme, 2014).
Operational definition
Obstetric factors: these are pregnancy related conditions which may arise during pregnancy or
labor which affect pregnancy and delivery process and predispose a patient to cs delivery. These
factors can be maternal, foetal or combined foetal and maternal factors.
Non-obstetric factors: these are non-pregnancy related situations that influence mode of
delivery or performance of caesarean section.
Extreme ages: these are ages below eighteen (18) and above thirty-five (35) which predispose
women to undergo caesarean section
Extreme birth weight: is the low birth below 2.5 kg and birth weight above 4.0 which can
predispose women to undergo caesarean section.
iii
ABSTRACT SUMMARY
The cause and related risk factor associated with caesarean section among women delivered at
Igawilo city hospital.
Caesarean section has been on the rise among pregnant women attending the maternity and labor
wards in Igawilo city hospital. The purpose of this study is to find out the cause and risk factor of
caesarean section among pregnant women delivered at Igawilo. The study design to be used is
descriptive cross sectional and the sampling technique will be probability sampling under
random sampling method. The sample size will be 264; this is due to limited time and scarce
financially resources.
Observational checklist, questionnaire and interview schedule will be used to gather information
from the maternity ward, labor wards, and reproductive health theatre registers and client files.
Data will be collected, coded, edited, clarified, analyzed and be presented in form of table, pie
charts and bar graphs.
Conclusion and recommendations will be drawn according to the findings of the research.
iv
TABLE OF CONTENTS
ACKNOLWLEDGEMENT.............................................................................................................i
LIST OF ABBREVIATIONS.........................................................................................................ii
DEFINITION OF TERMS..............................................................................................................ii
ABSTRACT SUMMARY..............................................................................................................iv
TABLE OF CONTENTS................................................................................................................v
CHAPTER ONE..............................................................................................................................1
1.1 Introduction...........................................................................................................................1
1.5 Objectives..................................................................................................................................4
1.7.0 Variable...................................................................................................................................5
1.8.0 Hypothesis..............................................................................................................................6
LITERATURE REVIEW................................................................................................................7
2.1 Introductions..............................................................................................................................7
v
2.3 Classifications C/S...................................................................................................................10
METHODOLOGY........................................................................................................................14
3.1 Introductions............................................................................................................................14
References......................................................................................................................................18
APPENDICES...............................................................................................................................20
vi
Annexure III: Questionnaire – English Versions...........................................................................22
vii
CHAPTER ONE
1.1 Introduction
On this chapter it comprises a background information’s, problem statement, rationale of the research,
broader/general and specific objectives, research questions, dependent and independent variables,
hypothesis formulations include both alternate and null hypothesis.
However, the procedure is very expensive to both hospital and expected mother. A cesarean section
poses document medical risk to mother health including infections, injury to other organs, anesthesia
complication, psychological problems, and maternal mortality two to four times greater than that of
vaginal delivered. An elective cesarean section increases the risk to baby of premature birth and
respiratory distress syndromes, both of them are likely associated with multiples complications,
intensive care unit and burdensome financial cost. Even a mature baby the absences of labor increases
the risk of breathing problems and others complications. Cesarean sections can be delayed the
opportunity for early mother newborn interactions, breastfeeding and the establishment of family
bonds.
8
The world health organization’s(who) states that no regions in the world would justified to having the
cesarean sections rate greater than 15% (1985) but the figure are based on theoretical estimations ,two
recent observations studies have supported that the recommendations (althabe,2006),(villar,2005) both
of studies assessed that the association between the c/s rates and mortality and morbidity in mother and
neonates have no any reductions in these indicators when the frequencies of c/s was more than 15%
but one studies shown that and increases of rate of c/s have directly to rates of interventions have
associated with high mortality and morbidity in mother and neonates (vilar,2005). Until further
research gives a new evidence rates greater than15% that my resulted to more harm than what expected
good, its therefore important to research on the cause and associated risk factor of cesarean section
among pregnant women delivered at Igawilo city hospital as to compared with the rates of who rates
and of other hospital around the world and to inform the policy maker and provide recommendations
for improving obstetric care practices.
In Tanzania, studies on caesarean section have been conducted in two referral hospitals. At
Kilimanjaro Christian medical Centre (kcmc), the trends of caesarean section deliveries from 2005 to
2010 ranges from 29.9% to 35.5%. The leading indication for operation was previous caesarean
section (worjoloh et al., 2012). While at muhimbili national hospital (mnh) the trend of caesarean
section rates from 2002 to 2011 raised from 19% to 49% (litorp, kidanto, nystrom, darj, & essén,
2013). The caesarean section rates of the two-referral hospital exceed the limit recommended by who
(nilsen et al., 2014).
9
However, there is limited study on caesarean section which have been conducted and published at
Mbeya zonal referral hospital (mzrh) which is one of the referral hospitals of Tanzania located in
southern highland zone. According to hospital report of 2014 and 2015 the averages of caesarean
section rates per month ranges from 36% to 42%.
Among factors attributed can be obstetrics and non-obstetrics which are social, demographic, cultural
and economic characteristics of pregnant women and medical practice and preferences of specific
organization (orsi & chor, 2006).
However, cesarean section among pregnant women delivered at Igawilo city hospital are rising
gradually from 4% to 9% in the last years and now days there is high number of pregnant women
delivered by cesarean section compare to the spontaneous vaginal delivered.
The aim of this study is intended to find out what are the cause and risk factor contributed to cesarean
section to women delivered at Igawilo city hospital, to assess the knowledge of health care provider on
behalf of delivered procedure and competences (examination, different maneuver employed in labor
ward, use of partograph to monitor labor progress and decision making on when to perform c/s ), to
find the obstetric indication of the c/s(obstructed labor ,fetal distress ,active infection on birth canal,
breech positions or cord prolapsed), to obtain a social-cultural practices related on c/s(alcohol,
smoking, psychological factor), to obtaining of health nutritional status related to the c/s(obesity,
height of mother) at Igawilo city hospital in Mbeya. This will contribute in the body of knowledge and
provide context specific recommendations on appropriate interventions to improve medical practice
particularly caesarean section.
10
1.4 Rationales of the Research
This study finding will be essential in planning of the reproductive health services, development of
protocol to be addressed in hospital and allocation of resources to maternity and reproductive health
theater. I anticipate that this study finding will help to improve of the antenatal mother management
due to the emergence obstetric and neonatal care (eonc), and will increase quality of life to patient,
baby and to provides recommendations on interventions and to develop policy brief on improving
obstetric practice especially reducing unnecessary caesarean section and finally going along to meet a
millennium development goal number 4 & 5(to reduce child mortality under five years, to improves
maternal health).
Also, this study will be the foundation for more studies to be conducted.
1.5 Objectives
To identify the causes and risk factor contributing to the cesarean section of pregnant women
delivered at Igawilo city hospital.
To assess the knowledge and competent of health care provider in the labor ward.
To identify the obstetric causes contributed to cesarean section delivered of pregnant women at
Igawilo city hospital.
To determine the social-cultural practice related to cesarean section delivered of pregnant
women at Igawilo city hospital.
To identify the nutrition status of pregnant women related to cesarean section at Igawilo city
hospital.
11
1.6. Research questions
The question to which will guide on carried out my research will be as follow bellow;
i. What are competence and procedure required to reduce the number of pregnant women
delivered by cesarean section at Igawilo city hospital?
ii. What are the obstetric conditions causing the cesarean section of pregnant women delivered at
Igawilo city hospital?
iii. What are the nutritional related risk factors of the cesarean section of pregnant women
delivered at Igawilo city hospital?
iv. What are the social-cultural practices related to cesarean section of pregnant women delivered
at Igawilo city hospital?
1.7.0 Variable
12
2. Obstetric condition related to cesarean delivered of pregnant women at Igawilo city hospital.
a. Fetal condition related causes fetal distress
b. Medical related condition like dm, anemia, epilepsy.
c. Maternal related cause obstructed labor.
3. The nutritional status related to cesarean delivered of pregnant women at Igawilo city hospital.
a. Height of the pregnant women.
b. Proportional of mass per square height (obesity).
4. The social-cultural practices related to cesarean section delivered of pregnant women at Igawilo
city hospital.
a. Alcohol
b. Smoking
c. Psychological problem
d. Age
1.8.0 Hypothesis
1.8.1 Alternate Hypothesis
i.There is chance of increased rate of pregnant women carried out cesarean section at low
experienced and competence health personnel.
ii.There increased rate of cesarean section to pregnant women whom will experience an obstetric
condition compared to normal.
iii.The obese and low height pregnant women have a high chance of carried out cesarean section
compared to normal.
13
2.0 CHAPTER TWO
LITERATURE REVIEW
2.1 Introductions
The caesarean section is a surgical procedure for delivering a baby, placenta and the placenta
membranes by cutting through the abdominal muscles to the uterus. The first modern caesarean section
was performed by dr James Barry in cape town, south Africa on 25 th July 1826 (cronjé, 2012.).
Caesarean section is usually performed when the normal vaginal would be risk for the mother or the
baby, however nowadays mother have always requested to be done caesarean section when there are
no indications, this has led to increase in its rates (cronjé, 2012.). Different countries have different
rates.eg china 40%, united states of America 33%, Italy 40% many Asian, European, and Latin
America countries the rates are around 25%. In these countries the rates also vary from hospital to
hospital e.g. In USA in 2009 in ranged been 6.9% to 69.9 % (peskin eg, 2002; ). The average rate of cs
deliveries is 3.5% in Africa, with highest rates in south Africa (15.4%), Egypt (11.4%) and Tunisia
(8%). Chad (0.4%), Madagascar, Niger and Ethiopia (0.6%) show the lowest cs rates in the world.
Central African Republic, Burkina Faso, Mali and Nigeria all show cs rates below 2%. In east African
countries it is 2.3% (world health organization, 1985 2:436-437.).
In Tanzania, the caesarean section rates are still low about 5% in 2010 (tdhs, 2010) and 6% in 2015
(tdhs, 2015). However, the health facility-based rates are still high compared to population-based
estimates (Nilsen et al., 2014).
The study conducted in Tanzanian referral hospital between 2005 and 2010 showed that the trend of
caesarean section rates has been increasing from 29.9% to 35.5%% (worjoloh et al., 2012). Litorp et al.
(2013) study revealed that the trend of caesarean section rates from 2002 to 2011 rose from 19% to
49%. And c/s recent study shown that there is increased from 2% in1996 to 6% in 2015-16, the main
mechanism sustaining the large increased of c/s was doubling in the monthly volume of it carried out
in the public hospital, to how overall 90% procedure was in public hospital than fbo institutions with
meet the requirement of the pregnant women (bjm open, 2018).
WHO has put caesarean section rates at 15% but it is not restricting it there? It gives every woman a
chance to deliver through it, if it is the best intervention at the time of her delivery. (world health
organization, 1985 2:436-437.)
14
2.2 Conceptual Model
This is a building block of existing knowledge through different literature review.
The conceptual model on determinants of caesarean section deliveries was modified from conceptual
model developed by tom joseph oguta in 2015 which describes the psychosocial determinants of
caesarean section deliveries.
Oguta’s (2015) conceptual model is based on social epidemiology theories which describes the
convergence of factors such as psychological state, personal traits, sexual behaviors, social experiences
and social interaction that link social conditions to important health outcomes.
This conceptual model is the joint of multiple factors that affect decision of caesarean section
deliveries at different levels of social environment which include individual, interpersonal, community,
organizational and public policy.
The conceptual model provides the basis for determining factors associated with caesarean section
deliveries. Hence, the concepts have been used in data collection tool and analysis to establish
determinant factors of caesarean section deliveries.
15
Figure 1. The figure below shows the conceptual model on the determinations of the caesarean
section’s delivery (oguta, 2015)
16
2.3 Classifications C/S
There are several categories of the c/s but most is based on characteristic of the mother as parity, model
of carried out procedures, onset of labor, gestational age, fetus presentations and number of fetus as by
Robson classifications (WHO, figure 02), however also can be listed as below;
classical caesarean section, which involves midline longitudinal incision which allows a larger
space to deliver the baby. It is rarely performed today, as it is more prone to complications.
An unplanned caesarean section is performed after labor pains have begun due to unexpected
labor complications.
A crash/emergent/emergency caesarean section is performed in an obstetric emergency, where
complications of pregnancy suddenly are known during the process of labor, requiring swift
action to prevent the deaths of mother, child or both.
A planned caesarean (or elective/scheduled caesarean), is arranged ahead of time, mostly due to
medical reasons and ideally as close to the due date as possible.
A caesarean hysterectomy is a caesarean section followed by the removal of the uterus. This
may be done in cases of intractable bleeding or when the placenta cannot be separated from the
uterus.
Traditionally, other forms of caesarean section have been used, such as extra peritoneal
caesarean section. (steven g. Gabbe n.d.)
a repeat caesarean section is one that is done when a patient had a previous caesarean section.
Typically, it is performed through the old scar.
The latitudinal caesarean section which involves a lower uterine segment section is the
procedure most commonly used today; it involves a transverse cut just above the edge of the
bladder and results in less blood loss and is easier to repair . (american congress of
obstetricians and gynecologists,n initiative of the abim foundation american congress of
obstetricians and gynecologists), , august 1, 2013,)
17
figure 02 . Robson classifications (who,2015)
18
2.4 Indications For C/S
The indications of caesarean section are also many as the clients to be performed on, some of them
include the following
Large baby weighing more than 4000gm
dystocia or prolonged labor
Fetal death
umbilical cord prolapsed and umbilical cord abnormalities, multilobate including bilobate and
succenturiate-lobed placentas, filamentous insertion
uterine rupture.
Increased maternal blood pressure and in the baby after amniotic rupture
Increased heart rate in the mother or baby after amniotic rupture
placental problems like low laying placenta or placenta accreta
Abnormal presentation which can be breech or transverse positions
Failed labor induction
There are also conditions that complicate pregnancy thus contribute to caesarean section; e.g.
Pregnancy induced blood pressure.
hypertension that existed before pregnancy only to complicate later in the pregnancy
multiple births, having more than one baby in single pregnancy
Previous scar most likely due to ruptured uterus.
human immunodefiencyvirus infection of the mother
Sexually transmitted infections, such as genital herpes (which can be passed on to the baby if
the baby is born vaginally or may cause obstruction during delivery
Previous classical caesarean section.
Prior problems with the healing of the perineum e.g. Crohn's disease)
bicornuate uterus
20
3.0 CHAPTER THREE
METHODOLOGY
3.1 Introductions
This will give the information on how the research would be carried out in respect to the description of
the study area, study or research designing, study populations that would include in the research based
on inclusions and exclusion, sampling procedure, sample size determinations, data collection
techniques, tools data processing, and analysis, disseminations of the results, ethical considerations as
well as study limitations.
21
3.3 Study Design
The study will be used a analytical cross-sectional study in which information’s will obtained about a
cause of CS and descriptive study will be used on to identify risk factor related to the raised rate of c/s
at Igawilo city hospital.
3.4 Study Populations
The study will involve all delivered pregnant women at Igawilo city hospital who admitted at
post-natal ward to collect the information’s.
22
n
Formula: nf =
1+n /N
Where nf = is the desired sample size
n = is the estimated total population less than 10, 000 and
n = is the estimated sample when the estimated total population (n) is greater or equal to
10, 000.
If n = 384 and now n is 839, what is nf?
nf = 384
1+ 384
839 =263.4 approximately 264
Then I will decide on randomly sampling procedure to obtain the participant of my study.
23
24
3.9 Data Processing and Analysis
In this study I’ll be use both qualitative and quantitative. Data will be obtained from this research study
will be manually calculated using scientific calculator and entered into a computer program of
Microsoft excel - worksheet where data will be processed and analyzed. Descriptive statistics will be
carried out to measure incidence rates and relative risk of the variables involved during the study.
3.10 Dissemination of Results
Final results of the study will be submitted to Mbeya College of health and allied science (MCHAS),
department of clinical medicine. It will be disseminated to Igawilo city hospital and finally will be
presented to the department of clinical medicine.
3.11 Ethical Considerations
The study will seek the ethical approval from MCHAS research ethic and review committee where the
permission to conduct this research will be obtained. Prior on providing questionnaire to respondents
the study should be explained to them with the purpose, benefits together with the rights of the
participants or any further clarification concerning the study will be asked.
Participants will be further given the consent form to read and for those who are unable to read will be
assisted and those who are willing to participate will sign the consent form before interview.
Confidentiality and privacy should be strictly observed, questionnaires number and initials should be
written instead of names, the information will be used for research purpose only and the participants
can be given advice.
25
CHAPTER FOUR
This section describes the study findings. The description of socio demographic characteristics of
respondents are presented first followed by independent variables which are obstetrics and non obstetrics
factors associated with caesarean section deliveries. The associations between independent variables with
mode of delivery are described by using Pearson Chi square test. The logistic binary regression model is
used to estimate the impact of independent variables on CS.
A total of 400 respondents were interviewed and their age ranged from 15 to 43 years with the mean age of
26.81 years (SD: 6.338). 20
Demographic distribution
15 – 24 162 40.5
25 – 34 182 45.5
35 – 44 56 14.0
Education level
Occupation status
26
Unemployed 110 27.5
Admission category
Payment category
Cash 9 2.25
IPPM 7 96
The majority of respondents 182 (45.5%) aged between 25 and 34, About 168 (42%) had secondary
education, and 290 (72.5%) were employed, majority of mothers 355 (88.75%) were married. Also
majority of mothers about 326 (81.5%) came direct from home (self referral) and few about 74
(18.5%) were referred from lower level hospitals. On payment category majority of mothers about
384(96%) were using National Health Insurance Fund (NHIF), 9 (2.25%) cash were using and 7
(1.75%) were under Intramural Private Practice Mbeya (IPPM) / (Fast track).
27
Attended 400 100.0
Number of visits
7+ 9 2.3
GA at first visit
4 – 12 91 22.8
13 – 24 255 63.8
25 – 36 54 13.5
Attended 50 12.5
Yes 21 5.3
No 379 94.8
28
29
30
31
32
33
34
53.5%
46.5%
42.0%
44.0%
46.0%
48.0%
50.0%
52.0%
54.0%
56.0%
Vaginal delivery
Caesarean section
Mode of delivery
All women reported to attend ANC clinic with mean number of visits of 3.9 (SD =1.236) and the mean of
gestational age at first booking is 18 weeks (SD = 6.365). Also 50 (12.5%) of women were attending
private clinic and 21 (5.3%) of women were attended by special doctors when admitted for delivery.
The rate of caesarean section among 400 postnatal mothers was 186 (46.5%).
35
36
37
38
39
Demographic Rate of CS (%) P – Value
distribution
35-44 56 40 (71.4)
Education 0.172
Employed 69 41 (59.4)
IPPM 7 7 (100)
41
4.2 Obstetrics factors associated with caesarean section
Table 4: Obstetric factors; maternal height, parity, GA during delivery, birth weight and Apgar score of
infants (N = 400) Factor
Variable Frequency Percentage (%)
Height
Parity
4+ 67 16.8
GA during delivery
28 to 36 119 29.8
37 to 42 281 70.3
Twins 4 1.0
7 to 10 381 95.3
4 to 6 15 3.7
0 to 3 4 1.0
42
None 361 90
PIH 16 4
Pre-eclampsia & 4 1
eclampsia
Genital warts 7 2
HIV/AIDS 12 3
Age
35 to 44 16 40 (71.4) 56
(28.
6)
Height
Parity
4+ 27 40 (59.7) 67
(40.
3)
GA during delivery
Twins 2 2 (50) 4
(50)
44
(45.9)
4 to 6 6 9 (33.3) 15
(66.
7)
0 to 3 2 2 (50) 4
(50)
4 to 6 6 (66.7) 9 15
(33.3)
0 to 3 2 (50) 2 (50) 4
conditions
7+ 4 (9.8) 37 (90.2) 41
45
46
The results show that the increase of caesarean section rate is associated with obstetric factors, the
factors which are statistical significant are; increase of maternal age (χ 2 = 16.410, df = 2, P < 0.001),
extreme maternal age / below 18 and above 35 years (χ 2 = 41.149, df = 1, P < 0.001), increase in parity
(χ2 = 5.638, df = 1, P < 0.05), extreme birth weight of below 2.5 kg and above 4.0 kg (χ 2 = 6.015, df =
1, P < 0.05), co morbid medical conditions such as PIH, pre-eclampsia, eclampsia and maternal
infections (P < 0.0001) and increase number ANC elective CS (χ2 = 37.713, df = 2, P < 0.001).
Other obstetric factors are not statistical significant such as; maternal (χ 2 = 0.076, df = 1, P > 0.05),
gestation age during delivery (χ2 = 0.981, df = 1, P > 0.05), APGAR score of the newborn (χ 2 = 1.168,
df = 2, P > 0.05), number foetuses delivered (χ2 = 0.20, df = 1, P > 0.05) and HIV/AIDS was not
statistical significant (P > 0.05)
74.2%
25.8%
Elective CS
This section comprise description of following is made; types of CS, number of CS done, indications of CS
and client’s satisfaction of the procedure.
The majority of caesarean section conducted were emergency CS which accounted for 138 (74.2) while 48
(25.8) were elective caesarean section.
47
Number of CS Frequency Percentage (%)
1 117 62.9
2 60 32.3
3 8 4.3
4 1 0.5
48
of caesarean section (N = 186)
Cephalo-Pelvic 35 18.8
Disproportional (CPD)
Malpresentation 22 10.7
PIH 16 8.6
Polyhydromnious 1 0.5
49
Client satisfaction on CS Frequency Percentage (%)
decision Client satisfaction
Yes 27 14.5
No 159 85.5
Yes 23 12.4
No 163 87.6
Yes 21 11.3
No 165 88.7
Yes 27 14.5
No 159 85.5
No 5 2.7
Prior consenting for CS, most of clients of about 159 (85.5%) were not given enough
information on risks and benefits of CS and didn’t understand what they were told, however
181 (97.5%) of the women were satisfied with the decision of undergoing CS.
1
4.6 Bivariate analysis of non obstetric factors associated with caesarean section deliveries
Cross tabulation of non obstetric factors and mode of delivery using chi-square was conducted to
establish the association, P – value was set to be statistical significant at cut of point of 0.05.
Time of delivery
Day of delivery
Marital status
Payment category
Employment status
2
Unemployed 64 (58.2) 46 (41.8) 110
Education level
The results show that the increase of caesarean section rate is associated with non obstetric
factors, the factors which are statistical significant are; marital status, CS rate is higher among
unmarried women (χ2 = 6.563, df = 1, P < 0.05), CS rate is higher among women with high
economic status under fast track (χ2 = 8.568, df = 2, P < 0.05) and women who are employed
The other factors were not statistical significant such as; time of delivery (χ 2 = 2.317 df =1, P >
0.05), day of delivery (χ2 = 0.121 df =1, P > 0.05) and education level (χ2 = 5.002 df =3, P >
0.05)
67.7%
3
64.5%
19.4%
6.5%
6.5%
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
Previous birth
experience
Prior CS delivery
Fear of vaginal
birth
Fear of losing
the baby
History of Intra
Uterine Fetal
Death
4
The factor which influenced women to prefer caesarean section delivery are; previous birth
experience 21 (67.7%), prior CS delivery 20 (64.5%), Fear of vaginal birth 6 (19.4%), fear of
losing the baby 2 (6.5%) and having history of Intra Uterine Foetal Death (IUFD) 2 (6.5%).
Friends 90 22.5
Relatives 14 3.5
Partner 10 2.5
Colleagues 1 0.25
women about 18 (4.5%) perceived caesarean section as safe mode of delivery while the
majority 382 (95.5%) perceive vaginal birth as the safe mode of delivery.
Reassurance of getting a 13 72
live baby
No labour pain 3 17
CS prevents 9 50
unnecessary neonate
5
death
Prevention of 36 9.0
neonatal death during
delivery
Prevention of 5 1.3
transmission of
infection to infant.
Obesity 45 11.3
6
babies
Participants had reported several factors which influences increase of caesarean section
deliveries such as fear of labour pain / vaginal birth 32 (8%), desire for their vaginal to remain
intact 32 (8%), desire for the baby with high IQ 4(1%), lack of exercise and laziness during
pregnancy 112 (28%), health problems during pregnancy 36 (9%), prevention of neonatal death
during delivery 36 (9%), Use of herbs 1 (0.3), use of contraceptives 20(5%), teenage pregnancy
14 (3.5%), prevention of transmission of infection to neonates 5 (1.3%), obesity 45 (11.3%),
influence of Health Care Provider 7 (1.8%), Fear of losing the babies 1 (0.3) and desire to
deliver few babies 2 (0.5%)
7
Payment 2.170 0.752 – 0.152 0.000 0.000 0.999
category 6.260
For identifying true predictors of CS, logistic binary regression model by using Hosmer and
Lemeshow Test was done. Women with extreme age (below 18 years and above 35 years) were
4 times likely to deliver by CS (AOR = 4.456, 95% CI: 2.404 – 8.258, P < 0.001), also
employed women were 2 times likely to delivery by CS (AOR = 2.303, 95% CI: 1.135 –
4.6721, P < 0.05), other factors like extreme birth weight (AOR = 1.564, 95% CI: 0.798 –
3.066) and high parity (AOR = 1.006, 95% CI: 0.508 – 1.991) show the risk of caesarean
section deliver although was not statistical significant (P > 0.05). Other factors didn’t show the
risk of CS deliver and were not statistical significant.
8
Payment 2.170 0.752 – 0.152 0.000 0.000 0.999
category 6.260
For identifying true predictors of CS, logistic binary regression model by using Hosmer and
Lemeshow Test was done. Women with extreme age (below 18 years and above 35 years) were
4 times likely to deliver by CS (AOR = 4.456, 95% CI: 2.404 – 8.258, P < 0.001), also
employed women were 2 times likely to delivery by CS (AOR = 2.303, 95% CI: 1.135 –
4.6721, P < 0.05), other factors like extreme birth weight (AOR = 1.564, 95% CI: 0.798 –
3.066) and high parity (AOR = 1.006, 95% CI: 0.508 – 1.991) show the risk of caesarean
section deliver although was not statistical significant (P > 0.05). Other factors didn’t show the
risk of CS deliver and were not statistical significant
CHAPTER FIVE
5.0 DISCUSSION
This study aimed at assessing factors associated with caesarean section deliveries which are
obstetric factors and non obstetrics factors. Among 400 post natal mothers who were
interviewed 186 (46.5%) delivered by caesarean section.
The results revealed that rate of caesarean section increase with increase in age, from 41% in
age group 15 to 24 to 71% in age group of 34 to 44. This study can be comparable to the study
conducted at MNH by (Muganyizi et al., 2008) which showed that the age group of 30 to 34
had highest risk of caesarean deliveries. Also is supported by another study conducted in UK
9
which revealed that the risk of caesarean section is increasing with maternal age (Black et al.,
2005). Pregnancy in older adults is accompanied with the risks such as; pre term births,
pregnancy induced hypertension, pre –eclampsia, foetus with genetic abnormalities, these risks
predispose them to caesarean section delivery.
Moreover this study showed the risk of caesarean section delivery is four times higher in
women aged below 18 and above 35 years. Also the results shows that, the rate of caesarean
section for under 18 is very high about 93.3% (P<0.001), this is due to the risks of premature
labour, low birth weight, pregnancy induced hypertension, poor progress of labour and social
consequences increases the risks of caesarean section delivery.
Another factor is parity which shows that the caesarean delivery rate increases with parity,
mothers who are para four and above have high rate of caesarean section. High parity has been
associated with pregnancy complications which predispose women to caesarean section
delivery. This study is also comparable to the study conducted at MNH by (Muganyizi et al.,
2008) which shows nulliparous mothers have lowest caesarean section rates while those with
previous caesarean deliveries have more than double risk of delivering by caesarean section. 39
Another obstetric factor is birth weight; findings showed that the rate of caesarean section
increases with increase extreme birth weight (below 2.5 kg and above 4.0 kg) the rate is 62%
while normal birth weight of 2.4 kg to 4.0 kg the rate is 44%. The study is related to the study
conducted in Oman by (Busaidi et al., 2012) which shows that extremes of neonatal birth
weight (<2.50 kg and ≥4.00 kg) were positively associated with caesarean section delivery.
Also the study by (Yoshioka-Maeda et al., 2016) revealed that women delivering babies with
low birth weight are at high risks of caesarean deliveries which can contributed by adverse
conditions like pregnancy induced hypertension and pre-term birth. Moreover is supported by
the study conducted in Lagos by (Olusanya et al., 2016) which showed low birth weight is
associated with the risk of caesarean delivery.
The results show that gestation age during delivery, maternal height and Apgar score of the
newborn had no significant in associating with caesarean delivery. This study is in contrast
with the study by (Yoshioka-Maeda et al., 2016) which showed that mothers with height below
150 cm are at risk of caesarean section deliveries. However this study had few participants with
maternal height below 150cm, mean height of respondents was 153.53cm.
10
Another factor is co-morbid illness which is associated with high risks of caesarean deliveries
such pregnancy Induced Hypertension (PIH) 93.8%, pre-eclampsia / eclampsia 100%, genital
warts 100%, however HIV/AIDS had low contributions to caesarean section deliveries of about
41.7%. The co morbid illness is explained by large number of caesarean deliveries as almost
95.7% of were under medical indications; the co-morbid illness has been associated with
pregnancy and labour complications which increases the risks of caesarean deliveries.
Furthermore, the results show that increase of caesarean section rate is associated with
increased number of ante natal visits (P < 0.001), the higher rate was elective caesarean section
as compared to emergency caesarean section (P < 0.001). This explains that co-morbid illness
contributed to many caesarean section deliveries as high risks pregnancy were closely observed
by nurse and midwives hence had many ante natal visits. 40
Majority of caesarean section conducted were emergency and accounted for 138 (74.2%) while
elective caesarean sections were 48 (25.8%). This study is similar to the study conducted at
MNH, which revealed that majority of caesarean section deliveries were by emergency
caesarean section which indicates that some women could have been delivered by elective
caesarean section (Mdegela et al., 2012). This also explains the reason why 95.7% of caesarean
section was conducted under medical indication while 4.3% were under maternal request
however was medically justified.
The leading indications of CS were previous scar 69 (37.1%), CPD 35 (18.8%), foetal distress
22 (11.8%), PIH/Pre-eclampsia 20 (10.8%), malpresentation 22 (10.7%) and prolonged labour
15 (8.1%) , this study is corroborates with the study conducted in Sub Saharan by (Kathyrin-
Chu et al., 2016) which revealed that; the most common indications of caesarean deliveries
includes; obstructed labour (31%), malpresentation (18%), previous Caesarean section (14%)
and foetal distress (10%), uterine rupture (9%) pre- eclampsia/eclampsia and ante partum
haemorrhage.
The non obstetric factors associated with caesarean deliveries include the following;
Socio economic status which is explained by category of payment and occupation which
reveals that the rate of caesarean section is higher among women with high socio economic
status as the rate for IPPM/fast track category of payment was 100% and employed women
11
59% compared to other category of payment and employment status. This can be compared
with Tanzania Demographic and Health Survey, 2016 which shows that women with high
socio economic status are eight times likely to deliver by caesarean section.
It is observed that the rate of caesarean section is higher among single women (61%) than
married women (45%). This can explain that social and economic support from the partners
reduces risks of caesarean section delivery. However the study is in contrast with the study by
(Inyang-Otu, 2014) revealed that there is no statistical significance in association between
marital status and mode of delivery. 41
Another factor is maternal request and preference. The study reveals that very few women
about 8 (4.3%) request caesarean section as well as very few preferred 31 (7.8%) caesarean
section delivery. This is similar to the study conducted in Italy which shows 6.4% preferred
caesarean delivery while majority preferred vaginal birth ( Gamble, Health, & Creedy, 2001),
also is supported by the study conducted in Dar es salaam which shows that majority of women
preferred vaginal birth (Litorp, 2015). Furthermore the study revealed that majority of women
about 170 (91.4%) has desire for vaginal delivery after undergoing caesarean section. Most
women prefer and desire vaginal birth because it is natural process with fewer complications
and are healed within short time compared to caesarean section delivery.
Among few women who preferred caesarean deliveries they are influenced previous birth
experience, prior caesarean section delivery, fear of vaginal birth, fear of losing the baby and
having history of Intra Uterine Foetal Death (IUFD). These factors have been attributed by
influence of friends, health care provider and relatives and previous birth experience which
influences them to have favourable attitude towards caesarean section deliveries.
Also majority of women about 85.5% reported to have individual choice on the mode of
delivery, 55.5% are influenced by health care provider, 22.5% influenced by friends and the
rest were influenced by relatives, partners and friends. Hence health care provider plays the
major role in influencing women on the mode of delivery. This study is supported by the study
done by (Litorp, 2015) which reveals that health care provider has emphasis in counselling
women on mode of delivery especially caesarean section.
Moreover few women about 18 (4.5%) perceived caesarean section as safe mode of delivery.
The reason for their perception is related to their previous birth experience such as; reassurance
of getting a live baby and prevention of unnecessary neonate death.
12
Moreover the factors associated with caesarean delivery explored from women were such as
fear of labour pain / vaginal birth this is supported by the study by (Storksen et al., 2001) which
reveals that fear of vaginal birth and previous birth experience contributes to caesarean
delivery. Also other explored factors were desire for their vaginal to remain intact (concern on
42
sexual practices), desire for the baby with high IQ, lack of exercise and laziness during
pregnancy, Health problems during pregnancy, Prevention of neonatal death during delivery,
Use of herbs, Use of contraceptives, teenage pregnancy, Prevention of transmission of infection
and diseases to infant during delivery, Obesity, Influence of Health Care Provider, fear of
losing the babies. The factors reported by women are due to their previous birth experience,
interpersonal and social influence and perception of caesarean delivery with the community.
These factors are moderate similar to the study conducted by (Oguta, 2015) on psychosocial
determinants of caesarean section delivery which are fear of child birth, concern on sexual
function, also another comparable study revealed that previous negative birth experience,
previous caesarean delivery, complicated pregnancy are associated with caesarean deliveries
(Handelzalts, Fisher, Lurie, Shalev, & Golan, 2011)
According to the conceptual model guided this study on the determinants of caesarean section
delivery. The study had identified that most of the obstetric factors such as maternal age,
parity, and co-morbid medical illness had contributed to caesarean section deliveries and non
obstetric factors involved economic status and social support and indications remained to be
foetal and maternal indications.
5.1 Conclusion
The rate of caesarean section at Mbeya Zonal Referral hospital is relatively high. There is the
need to reduce to the reasonable/optimum rate; this can be achieved by reducing unnecessary
cesarean deliveries among women with low risks. Health care providers should be aware of the
risks of unnecessary caesarean section as well as women should be fully informed on benefits
and risks of caesarean section
13
2 Study limitation and strength
Study limitation
The study was conducted in public referral hospital only which might miss some of the non
obstetric factors in private hospitals. The results may not be generalized to other settings of lower
level and general population.
Missing some information which was acquired from patients records such as maternal height, birth
weight, Apgar score and gestation age during delivery.
Strength
The rate of caesarean section in Tanzania is 6% and the rate of caesarean section at Mbeya Zonal
Referral Hospital is 46.5%. This was the appropriate setting to assess factors associated with
caesarean section. Also due to limited published studies conducted at Mbeya Zonal Referral
Hospital, this study is the foundation for other studies to be conducted.
5.3 Recommendations
The study shows that caesarean section deliveries have been largely contributed by medical
indications whereby leading indication was previous scar, so prevention of unnecessary primary
caesarean section may reduce caesarean section deliveries; also maternal age and parity are factors
which mainly contributed to caesarean section delivery however majority of women prefers vaginal
delivery even after caesarean section. This may enhance conducting safe vaginal birth after
caesarean section. To improve the practice of conducting caesarean section the following is
recommended.
1. Ministry of Health, Community Development, Gender, Elderly and Children may incorporate the
Midwives Model of Care in Reproductive and Child Health (ANC and Post partum care) services
which focuses holistically on the well being of the mother throughout the pregnancy and
postpartum as emphasis natural birth and reduces the number of high risk pregnancies and the need
for caesarean section.
44
2. Ministry of Health, Community Development, Gender, Elderly and Children may consider
strengthening family planning services to increase coverage and emphasis on youth friendly
14
reproductive health services; this will reduce high parity and teenage pregnancy and hence reduce
caesarean section deliveries.
4. Mbeya Zonal Referral Hospital should develop and operationalise guideline for safe conduct of
vaginal birth after caesarean section as leading indication for CS is previous scar.
5. Mbeya Zonal Referral Hospital management should consider regular coaching of staff on
appropriate foetal monitoring.
6. Mbeya Zonal Referral Hospital management may plan to conduct audit for caesarean section.
7. Health Care Provider (Midwives and Doctors) should provide psychological support to women
throughout pregnancy until delivery and emphasis on natural birt
15
REFERENCE
aidan m, e. G. (n.d.). Tanzania mothers’ cultural belief and misinformation regarding the
reason for caesareans sections. Aku.
Alan h. Decherney, m. L. (n.d.). Current diagnosis and treatment in obstetrics and
gynaecology. S.l.:s.n.
Andrea b.p, f. O. (n.d.). Caesarean section provisions and readiness in tanzania: analysis of
cross-sectional survey of women and health facility over times .bmj open access.
Betran, a. P. (n.d.). Who statement on caesarean section rates. Bjog: an international journal
of obstetrics & gynaecology.
Cronjé, h. 2. (n.d.). "clinical obstetrics. A south african perspective". 3rd ed. In: s.l.:s.n., p. 3:
345..
Dc dutta’s (2015), t. O. (n.d.). Editions 8, by jaypee bmp, chapter 37, pg 692-702.
Esteves-pereira, a. P.-t.-p.-c. (2016). Caesarean delivery and postpartum maternal mortality: a
population-based case control study in brazil. Plos one, 11(4), e01533.
H., a. ((2017), ... ). Improving the quality of caesarean sections in low-resources setting. An
intervention by criteria –based audit at a tertiary hospital, dar es salaam, tanzania.
Liu s, l. R. (n.d.). Maternal mortality and severe morbidity associated with national
collaborating centre for women's and children's health., 2004. Caesarean section: .
Louse c, j. E. (n.d.). 20 editions, chapter 13, and pg 446- 476.
Oguta, t. J. (n.d.). Psychosocial determinants of elective cesarean section deliveries in selected
obstetric facilities in nairobi, kenya (doctoral dissertation, walden university, 2015).
Walden dissertations and doctorial studies, 12(04).
Orsi, e. D. (n.d.). (2006). Factors associated with cesarean sections in a public hospital in rio
de janeiro , brasil, 22(10), 2067–2078.
Peskin eg, r. G. (n.d.). . What is the correct caesarean rate and how we get there?. Obstetrical
& gynaecological survey , pp. 57:189-190..
Report, m. Z. ((2015).). Annual hospital deliveries report of 2015, mbeya, tanzania.
Souza, r. D. (n.d.). Best practice & research clinical obstetrics and gynaecology caesarean
section on maternal request for non-medical reasons : putting the uk national institute
of health and clinical excellence guidelines in perspective. Ybeog, 27(2), .
Thomas j, p. S. (n.d.). Royal college of obstetricians and gynaecologists clinical effectiveness
support unit. The national sentinel caesarean section audit, london, united kingdom::
16
rcog press.
Worjoloh, a. ,. (n.d.). Trends in cesarean section rates at a large east african referral hospital
from 2005-2010. Open journal of obstetrics and gynecology, 2(03), 255.
World health organization, 1. 2.-4. (n.d.). Appropriate technology for birth., geneva: lancet ;. .
Ye, j. Z. (n.d.). Association between rates of caesarean section and maternal and neonatal
mortality in the 21st century: a worldwide population‐based ecological study with
longitudinal data. Bjog: an international journal of obstetrics & gynaecology,
1111/1471-0528, 13592.
17
APPENDICES
Annexure I: Work Plans
18
Annexure II: Estimated Budget
Items Days Quantity unit cost total cost
Stationeries
Pen 5 200.00 1,000.00
Rubber 1 500.00 500.00
Pencil 5 100.00 500.00
Ruler 1 500.00 500.00
Notebook 2 1,000.00 2,000.00
Duplicating paper (ream) 1 15,000.00 15,000.00
Stapler pins 1 1,000.00 1,000.00
Correction fluid 1 1,000.00 1,000.00
Secretarial services
Printing and photocopying research
proposal 1 5,500.00 5,500.00
Printing and photocopying research work 1 15,000.00 15,000.00
Binding research work and research
proposal 1 1,000.00 1,000.00
Meals 28 1,000.00 28 ,000.00
Transportation 28 1,400.00 39,200.00
Accommodations 28 1,500.00 42,000.00
Communications 28 500.00 14,000.00
Contingency fund 10,000.00
Grand total 167,200.00
Table 2: estimated budget
19
Annexure III: Questionnaire – English Versions
Section A: Demographic
(encircle one’s correct answers)
Age
2. No
2.cash
3.examptions
20
Section B: Assessment of C/S
(tick where it is no or yes and writing were indicated)
Part 1. Obstetric information’s
Month of admission _____________study number ----------------- ADM-
NO___________________ age- (years) ____________
D.O.A ________________time. _______________D O D__________________.
Weight------------------------------
Highest level of education 1. none ________ 2. primary ________3. secondary________
4 tertiaries__________ _occupation_____________
Residence of patient’s location__________________
Parity ________________previous abortions_____________
gravidity_______________________________________________
Height of the mother (check antenatal card) ____________ date of diagnosis of c/s_____
section________________________ What was the gestational age during delivery? (check the file) _________
What was the birth weight of the newborn(s)? (check the file) _______________________
How many infants did you gave birth 1) single tone fetus ------------2) multiple fetuses--------
Did you have any medical conditions? (check file & records multiple responses)
21
1) none-------- 2) gestational diabetes mellitus ---------
What was your mode of delivery?1) vaginal delivery-------2) caesarean section delivery---------
Before coming to hospital, what was the mode of delivery did you expect to deliver? 1)
vaginal delivery___________2) caesarean section delivery________
Indication of c/s
________________________________________________________________
Who made decision of conducting cs? 1) health care provider______2) client_____3) client’s
partner____4) other ____________________
22
Did your doctor or midwife explain to you the benefits and risks of cs? 1) yes ____2)
no________
Did the information help you to consent for operation? 1) yes______2) no_____
Were you satisfied with decision of caesarean section delivery? 1) yes _______2)
no______
Interoperation complication
1. None_____________ 2.
Complications______________________.3.not
indicated______________________
Outcome of c/s
Baby
23
______c) infections_______d) burst abdomen___________
Do you have desire for vaginal delivery after this caesarean section delivery?
1) yes______ 2) no___________
_________________________
What was the day of delivery? E.g. (Monday, Saturday and Sunday)
_____________________________
If your choice was cs, what influenced your decision? (tick all that applies) 1) previous birth
experience_____2) fear of vaginal birth (ask why?)
_____________________________________________________________
Which mode of delivery did you believe was safe for you and the baby?
1) vaginal delivery _______2) caesarean section______3) none______
24
If you are advising a relative, friend or colleague on safe mode of delivery, which mode
will you influence her to opt? 1) vaginal delivery______
2) Caesarean section ____________
25
Kiambatanisho IV: Dodoso - Swahili Version
Sehemu A: Taarifa Binafsi
26
Sehemu Ya B: Uchunguzi Wa Kujifungua Kwa Upasuaji
1) ndiyo_________2) hapana________
Je, ulianza kliniki mimba ikiwa na wiki ngapi (ga)? (angalia kadi ya kliniki)
_______________________
1) ndiyo_______2) hapana________
27
Je kwa sasa hapa hospitalini, unahudumiwa na daktari wako maalumu?
1) ndiyo________2)hapana________
Je, ulijifungua mimba ikiwa na umri gani (gestational age)? (angalia faili______________
______
Je ulikuwa na shida yoyote au ugonjwa wakati waujauzito? (angalia faili, jibu zaidi ya moja)
1) hapana______2) kisukari (diabetes mellitus_____3) ugonjwa wa moyo
4) shinikizo la damu wakati wa ujauzito (pih)_____ 5) kifafa cha mimba (pre – eclampsia /
eclampsia)_______ 6) vvu / ukimwi_______7) maambukizi ya mama_____
8) nyinginezo_______________
28
29
Sehemu Ya 4: Sababu Za Kitaalamu (Indications) Za Kukufanyia Upasuaji
Kama ilikuwa ni tatizo la ujauzito / uzazi, ni tatizo gani liilopelekea ufanyiwe upasuaji
(indication of caesarean section)? (angalia faili)
31
Confidentiality
All collected information will be kept confidential and this will be maintained by using codes
and no names will be asked or required. Information collected on questionnaire will be entered
into computers with only the study identification number and if the results of the current study
Will be published or presented in a scientific meeting, names and other information that might
identify you will not be used.
Benefits
There will be no direct benefit for your participation; however, the study findings will help to
identify the causes and factors contributing to caesarean section rates and hence strategize way
forward to reduce. That can be achieved by alerting the policy makers on the magnitude of the
situation which will lead to develop policy which will improve the quality of health care
provider decision making to conduct only justifiable caesarean section and fostering vaginal
delivery among women with uncomplicated pregnancies and labor.
Compensation:
There will be no compensation of any kind in participation.
Risk
The study will not harm you physically, psychologically or emotionally.
Rights to withdraw and alternatives
Participation in this study is voluntarily and you have the right to refuse to participate or
withdraw from the study even if you have already given your consent. Refusal to participate or
withdraw from the study will not involve penalty or loss of any benefits to which you are
otherwise entitled.
32
Who to contact?
If you ever have questions about this study, you should contact the head of department madam
Albertina of Mbeya college of health and allied sciences’(MCHAS) and madam mkola my
supervisor of this study by address of po box 1142, MCHAS, Mbeya Tanzania
Signature:
Do you agree to participate? Put √ in appropriate box
Participant agrees participant does not agree
I, ___________________________________ have read the contents in this form. My
questions have been answered. I agree to participate in this study.
Signature of participant ___________________________________date ___________
Signature of the researcher ________________________________date___________
33
Kiambatanisho VI : Ridhaa Ya Kushiriki Katika Utafiti
34
Haki ya kujitoa katika utafiti
Ushiriki wako katika utafiti huu ni hiari yako na una haki kukataa kuto kushiriki au kujiondoa
katika utafiti huu hata kama umetoa kibali cha kushiriki. Kukataa kushiriki au kujiondoa katika
utafiti hutatoa fidia au kupoteza faida zako.
Nani wa kuwasiliana
Kama kuna swali lolote lile kuhusu utafiti huu, wasilliana mkuu wa idara ya Utabibu chuo cha
afya na sayansi shirikishi Mbeya na msimamizi wangu mkuu wa utafiti Sanduku la Posta 1142,
MCHAS, Mbeya-Tanzania.
Je? Unakubali kushiriki,
Weka alama ya tiki (√) katika kisanduku husika
ndiyo hapana
Mimi, ___________________________________ nimeelezwa / nimesoma maelezo yote ya
fomu hii na nimejibiwa maswali yangu yote. Nimekubali kushiriki katika utafiti huu.
Sahihi ya mshiriki _______________________________tarehe ___________
Sahihi ya mtafiti ________________________________ tarehe ___________
35
36