27 November 2012

Namibia: Caesarean Sections At a Mission Hospital - a Six-Year Review (2001-2006)


MATERNAL and infant (peri-natal) mortality and morbidity (that is, deaths and other adverse outcomes in mothers and their newborn and unborn offspring) are a significant measure of a nation's development.

There is already a sufficient groundswell of statistics to indicate the upward trend of this indicator in Namibia that has attracted a critical mass of opinion and calls for action at national and international platforms to regress the trend. The roadmap for redressing this situation is no doubt shaped through a multi-sectoral approach, involving state, non-state and international players. The role of local research to provide the fodder of information for focused action cannot be overemphasized and the dearth thereof has already been stated in a plethora of press reports by government and other stakeholders already.

In the absence of a medical or health journal accessible to Namibian health and non-health professionals whose individual and collective roles in the society influence how state and non-state resources are deployed for improvement of the health status of citizens, I wish to utilize this coveted space in the your esteemed newspaper to share a summary of the findings of an ethically sanctioned academic research project for a Master's degree in Public Health done using records at a local health institution in northern Namibia.

Background and Motivation for the Research

The outcomes of pregnant mothers and their babies are directly influenced by the quality of obstetric services. The World Health Organisation (WHO) and United Nations Family Planning Agency (UNFPA) have thus set guidelines to monitor obstetric services quality through specific indicators that assess progress of availability of emergency obstetric care (EOC) services in every country. Caesarean section rate (CSR) is one such indicator, defined as the percentage of all pregnant women who deliver through a caesarian section for their sake, their unborn babies' sakes or both.

The WHO believes CSR (if caesarean sections are not overused for inappropriate indications) can be a proxy for maternal mortality based on the premise that women who fail to access caesarean sections when it is needed die (AbouZahr1 and Wardlaw, 2001). The minimal acceptable level is 5 percent to a maximum of 15 percent of all births. A CSR of less than 5 percent may indicate under-coverage, whereas an excess of 15 percent may mean a lot more unnecessary operations are being done.

Contrary to a global epidemic of caesarean delivery, whereby in most other continents the number of women delivering through caesarean section is increasing rapidly or has been sustained at high levels as much as 40 percent of all births, much of sub-Saharan Africa countries are unfortunately regressing in terms of this important indicator of a life saving procedure.

Most "unnecessary" indications for caesarian sections spurring a global upsurge have been noted in various reports and studies as maternal demand especially due to fear of vaginal birth with respect to potential pain of labour and genital trauma; fear of ligation and a financial motive by medical practitioners and health facilities.

Research Objectives and Methods

Both extremes (too high or too low caesarean rate) necessitate an internal audit or operational research. Therefore, the study was conducted at a local district hospital to ascertain the levels and trend of this essential obstetric service (caesarean delivery) and also determine the indications and feto-maternal outcomes. A quantitative design was used that involved a retrospective review of maternity and theatre registers for the period 1st January 2001 to 31st December 2006. A full census of all eligible cases was done.

Sources of data included delivery registers, the health information system 2000 (HIS2K) maternity (in-patient) department, monthly summary reports and the major theatre procedure record book.

Research Findings

Appropriate statistical methods were employed to analyze the data. A mean CSR of 5.2 percent was realised over the 6-year study period (423 caesarean sections out of 8 1089 deliveries). Further data analysis showed that there was a significant upward trend in the number of caesarean deliveries relative to normal deliveries between 2001 and 2006 though, with a range of 3.1 percent to 6.4 percent - the rate was well within acceptable levels, indicating an improved coverage over the period under review.

Cephalopelvic disproportion (where the health worker presumes the head of the child is too large for the pelvic opening) was noted as the most preponderant indication 149 (35.2 percent) followed by fetal distress (where the heart of the fetus has become abnormal for any external or internal cause) at 68 (16.1 percent). Over 80 percent of the operations were performed as emergencies.

Mothers were mostly in the 20-24 age group (33 percent), and mostly first-time mothers (52 percent). Maternal mortality was <1 percent. Of the 448 babies, 89 percent were singletons, 60 percent males, and 72 percent weighed between 2501-3500 grams. Also, 95 percent of the babies were discharged alive, and 5 percent (17 singletons and 5 of the twins) died after the operation. Neonatal mortality was significantly associated with fetal indications than with maternal indications, meaning that, of the few newborns who died, there was a higher risk of death if the reason why the operation was called was for a reason that the fetus was having some problems and thus required urgent delivery.

Conclusion and Recommendations

The average caesarean section rate of 5.2 percent (range 3.1-6.4 percent) was just within the 5-15 percent threshold as recommended by the WHO. It was heartening to note that post-operative feto-maternal outcomes were comparatively low, even though this is a district hospital without resident obstetric specialists. It was found that where newborns died, the causes were sometimes unavoidable (such as severe congenital fetal abnormalities); and for some it is possible that mortality could have been avoided with sophisticated infrastructure or better resuscitation efforts or rather identification of other structural or operational factors that are amenable to specific intervention.

The study recommended that similar trend series studies be conducted at all referral, district, and private hospitals in Namibia in order to establish both a local hospital and national picture of CSR, indications and feto-maternal outcomes as an audit of this essential obstetric service. The results/findings, good or bad, would need to be published, freely shared or stored in a central repository for benchmarking future trends or with other countries.

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