CHAPTER TWO

Literature review
2.0 INTRODUCTION
In this chapter the researcher will be focused theoretical view the demographic factor maternal
health status physiological factor Factors associated with Caesarean section among pregnant
women

2.1 THEORATICAL VIEW

For nearly 30 years, the international healthcare community has considered the ideal rate for
caesarean sections to be between 10% and 15%. This was based on the following statement by a
panel of reproductive health experts at a meeting organized by the World Health Organization
(WHO) in 1985 in Fortaleza, Brazil: here is no justification for any region to have a rate higher
than 10-15%”. The panel’s conclusion was drawn from a review of the limited data available at
the time, mainly from northern European countries that demonstrated good maternal and
perinatal outcomes with that rate of caesarean sections. Since then, caesarean sections have
become increasingly common in both developed and developing countries for a variety of
reasons . When medically justified, caesarean section can effectively prevent maternal and
perinatal mortality and morbidity However, there is no evidence showing the benefits of
caesarean delivery for women or infants who do not require the procedure. As with any surgery,
caesarean sections are associated with short- and long-term risk which can extend many years
beyond the current delivery and affect the health of the woman, her child, and future
pregnancies. These risks are higher in women with limited access to comprehensive obstetric
care Caesarean sections continue to increase worldwide. No agreement has been reached on an
appropriate caesarean section rate, and views are mixed on whether too many are being carried
out. Many women enquire about caesarean section as an option for delivery, and a significant
number request a caesarean section. Most women do not want an operation, they request a
caesarean section because they do not want to labour and deliver vaginally. Nulliparous women
request a caesarean section because they are worried about something that may happen.
Multiparous women request a caesarean section because of something that did happen. National
guidelines have reinforced the right of women to decide the mode of their delivery provided that
they have been counselled appropriately. If an obstetrician disagrees with the woman's decision
to deliver by caesarean section, then she should be referred to an obstetrician who would be
prepared to carry out the caesarean section

Different rates of caesarean section in public and private patients suggest that non-medical
factors, such as economic gain and pressures of private practice, may motivate doctors to
perform surgical deliveries. Alternatively, these differences may reflect patients' preferences and
result from informed choices about type of delivery. In Brazil, choosing between these
interpretations is contentious as the rate of caesarean sections among private patients is
extremely high and more than twice the rate in the public sector. About one quarter of all
deliveries take place in the private sector, and more than 70% of those are by caesarean
section. Such a rate cannot be attributed to the actions of a fraction of the obstetricians with
private practice or the prevalence in the population of the usual medical indications for caesarean
delivery. The most doctor friendly, but still problematic, explanation is a strong preference for
surgical deliveries among the upper and middle class women who are most likely to have private
medical insurance.

Twin pregnancies are associated with increased perinatal mortality, mainly related to
prematurity, but complications during birth may contribute to perinatal loss or morbidity. The
option of planned caesarean section to avoid such complications must therefore be considered.
On the other hand, randomized trials of other clinical interventions in the birth process to avoid
problems related to labor and birth (planned caesarean section for breech, and continuous
electronic fetal heart rate monitoring), have shown an unexpected discordance between short‐
term perinatal morbidity and long‐term neurological outcome. The risks of caesarean section for
the mother in the current and subsequent pregnancies must also be taken into account.

Caesarean section rates are progressively rising in many parts of the world. One suggested
reason is increasing requests by women for caesarean section in the absence of clear medical
indications, such as placenta previa, HIV infection, contracted pelvis and, arguably, breech
presentation or previous caesarean section. The reported benefits of planned caesarean section
include greater safety for the baby, less pelvic floor trauma for the mother, avoidance of labor
pain and convenience. The potential disadvantages, from observational studies, include increased
risk of major morbidity or mortality for the mother, adverse psychological sequelae, and
problems in subsequent pregnancies, including uterine scar rupture and a greater risk of stillbirth
and neonatal morbidity. The differences in neonatal physiology following vaginal and caesarean
births are thought to have implications for the infant, with caesarean section potentially
increasing the risk of compromised health in both the short and the long term. An unbiased
assessment of advantages and disadvantages would assist discussion of what has become a
contentious issue in modern obstetrics.

Pregnancy and delivery are considered as normal physiological phenomena in women.

Approximately, 10% deliveries are considered as high risk, some of which may require
caesarean section. The first modern caesarean section was performed by German gynecologist
Ferdinand Adolf Keher in 1881. Caesarean section is normally performed when a vaginal
delivery would put the mother and baby’s life at risk but sometimes it is also performed on
request. In recent years the rate has risen to a record level of 46% in China and 25% or above in
many Asian and European countries, Latin America and USA1. Caesarean section is common
surgical operation now and most estimated prevalence rate of 33%; prevalence ranges from 4%
in Africa to 29% in Latin America and Caribbean

Caesarean section (CS) performed in an emergency can be life-saving for both the pregnant
woman and her baby. In Nigeria, CS rates have been estimated to be 2.7% nationally, with the
highest regional rate of 7.0% reported in the South-West of the country. Our objective in this
facility-based retrospective cross-sectional study was to describe patterns and assess factors,
obstetric indications, and outcomes of emergency CS in Lagos, Nigeria.

Caesarean section refers to a surgical procedure whereby the baby is removed from the mother’s
uterus through an incision in the abdominal wall . It is the most common Obstetric surgical
operation in developed societies, as it is considered the safest procedure to resolve complications
of vaginal birth and maintain fetal wellbeing . Caesarean section has been a part of human
culture since ancient times, and there are historical records in both Western and Eastern cultures
of this procedure resulting in healthy mothers and offspring Numerous references to caesarean
section appear in ancient Hindu, Egyptian, Grecian, Roman and other European folklore
Furthermore, in 1988, American College of Obstetrician Gynecologist ( recommended that, in
the absence of a contraindication, a woman with one previous low transverse Caesarean delivery
should be counselled
A caesarean delivery without maternal involvement in decision-making reduces the quality of
health care and breaks women’s autonomy. However, the involvement of women in decision-
making to have a caesarean delivery is minimal. Still, now paternalism is widely practiced. The
study aims to assess women’s involvement in decision-making and associated factors among
women who underwent a caesarean delivery.

The most frequent major surgical procedure performed in the UK is a caesarean section (CS). At
National Health Service hospitals in 2016–17, there were 636 401 births; of these, 27.8% were
delivered using CS. CS includes potential dangers, for example, a chance of developing a
surgical site wound infection (SSWI). It might be mild, like an infection of a cut, or more
dangerous, like endometritis, which affects deep tissue or the organ space. Presently, the World
Health Organization (WHO) and the National Institute for Clinical Excellence (NICE)
recommend giving one prophylactic broad-spectrum cephalosporin before making a skin incision
because doing so cuts the incidence of SSWIs by 50%. 7 Women who have CS are still 5–10
times more likely than women who give birth vaginally to acquire an SSWI, even with antibiotic
prophylaxis. This risk is still very high for both superficial and organ-space SSWIs, with 7% to
20% of women suffering wound infections and 4% to 18% of women developing endometritis,
respectively. Moreover, comorbidities such as obesity and diabetes, which substantially raise the
risk of SSWI, are becoming more common. In the last 20 years, obesity has more than
quadrupled, with 58% of the females now classified as obese while diabetes has increased by a
factor of two, affecting 5% of pregnancies

Parturient undergoing caesarean section in general anesthesia have an increased risk of

desaturating during anesthesia induction. Pre- and peri-oxygenation with high-flow nasal oxygen
prolong the safe apnea time but data on parturient undergoing caesarean section under general
anesthesia are limited. This pilot study aimed to investigate the clinical effects and frequency of
desaturation in parturient undergoing caesarean section in general anesthesia pre- and peri-
oxygenated with high-flow nasal oxygen and compare this to traditional pre-oxygenation using a
facemask.
2,2 DEMOGARAPHIC FECTOR
A study conducted in Pakistan was found Overall prevalence of CS was 13.1% across the four
hospitals. 728 patients were approached and 717 responded to the survey. Although 78.8%
perceived CS as dangerous, influenced by education, locality and employment status 74.5% of
patients were in agreement that this is the best approach to save mother’s and baby’s lives if
needed. 62% of respondents reported they would like to avoid CS if they could due to post-
operative pain, and 58.9% preferred a normal delivery. There was also a significant association
with education and locality where respondents considered normal vaginal delivery as painful

A study conducted in European one hundred and five units and 1530 obstetricians participated
in the study (response rates of 70 and 77%, respectively). Compliance with a hypothetical
woman’s request for elective caesarean section simply because it was ‘her choice’ was lowest in
Spain (15%), France (19%) and Netherlands (22%); highest in Germany (75%) and UK (79%)
and intermediate in the remaining countries. Using weighted multivariate logistic regression,
country of practice, fear of litigation and working in a university-affiliated hospital were
associated with physicians’ likelihood to agree to patient’s request. The subset of female doctors
with children was less likely to agree.

A study conducted in Pakistan was found the mode of delivery was used as the response variable
in this study. The question was posed by inquiring about the women’s preferred technique of
delivery. There are two options: a CS or a VD. Women in this study underwent CS in 75.66% of
cases and delivered vaginally in 24.34% of cases. The relationship between mode of delivery and
demographic maternal risk factors is shown in Table 3. When compared to women who had VD,
the mean age of women with CS was consistently higher (29.19 years) as compared to women
with VD (24.24 years) in our study sample. A considerable proportion of the women (38.87%)
had completed primary education, among whom (30.06%) preferred CS as their mode of
delivery. In the sample, the majority of women (65.53%) resided in urban areas, and intriguingly,
50.88% of them opted for CS. The Chi-square results reveal that there is a link between
education, age, residential area and mode of delivery.

2.3 METERNAL HEALTH STATUS

A study conducted in CANADA was found Rates of CS increased with advancing maternal age;
in women aged 20 to 34, 35 to 40, and over 40, the rates were 26.2%, 35.9%, and 43.1%,
respectively. The top three Robson groups by contribution to CS rates involved women who had
one or more of the following factors: previous Caesarean section, primiparity, conception by
means of assisted reproductive technology, chronic hypertension, gestational diabetes, diabetes
mellitus, preeclampsia, placenta previa, placental abruption, or large for gestational age infants.
The prevalence of these factors increased with advancing maternal age, yet mothers aged ≥ 35
with one or more health conditions or obstetrical complications had higher CS rates than mothers
aged 20 to 34 with the same condition or complication.

A study conducted in NIGERIA was found Almost three-quarters (72.4%) of all births were to
multiparous women, with a singleton baby of normal birthweight, thus a low-risk group similar to Robson
3, and with a CS rate of 1.0%. CS rates in the two high-risk groups (multiple pregnancy and preterm/low
birthweight) were low, 7.1% (95% and 1.8 % (95% , respectively. The ENMR was particularly high for
multiple pregnancy (175 per 1000 live births; 95% . Greater number of antenatal visits, unwanted
pregnancy, multiple pregnancy, household wealth, maternal education, Christians/Others versus Muslims
and referral during childbirth were positively associated with CS.

A study conducted in SWEDEN was found Placenta previa was recorded in 4.4 per 1000 second-
birth singletons whose first births delivered by caesarean section and 2.7 per 1000 second-birth
singletons whose first births delivered vaginally. About 6.8 per 1000 births were complicated
with placental abruption in second-birth singletons whose first births delivered by caesarean
section and 4.8 per 1000 birth in second-birth singletons whose first births delivered vaginally.
The adjusted odds ratio (95% CIs) of previous caesarean section for placenta previa in following
second pregnancies was after controlling for maternal age, race, education, marital status,
maternal drinking and smoking during pregnancy, adequacy of prenatal care, and fetal gender.
The corresponding figure for placental abruption
2.4 PSYCHOLOGICAL FACTOR
A study conducted in NORWEY was found in this study, a total of 3.5% of the primiparous and
9.6% of the multiparous women preferred a CS when asked during pregnancy. After adjusting
for the sociodemographic, psychological and obstetric factors, a CS preference was associated
with FOC and an educational level between 10 and 13 years in both groups, symptoms of
depression and age over 35 years old among the primiparous women, and a previous CS and
negative birth experience among the multiparous women. The multiparous women in Tromsø

A study conducted in EUROPEAN was found In total 97 women (3.6%) had very negative
feelings and about half of them subsequently underwent counselling. In addition, 193 women
(7.2%) who initially had more positive feelings underwent counselling later in pregnancy. In
women who underwent counselling, fear of childbirth was associated with a three to six times
higher rate of elective caesarean sections but not with higher rates of emergency caesarean
section or negative childbirth experience. Very negative feelings without counselling were not
associated with an increased caesarean section rate but were associated with a negative birth
experience.

A study conducted in EUROPEAN was found Fear of both childbirth and pain were both
independent predictors of preference for ECS. Catastrophizing mediated the relationship between
fear of pain and preference for ECS. Interventions that target these factors may reduce the trend
towards increasing numbers of ECS internationally.