Prevalence and associated factors of caesarean section in Addis Ababa hospitals, Ethiopia

Introduction Caesarean section refers to the operation of delivering a baby through incisions made in the mother's abdominal wall and uterus. A caesarean section is medically indicated when a significant risk of adverse outcome for mother or baby is present. The objective of this study was to assess the prevalence and associated factors of caesarean section in Addis Ababa Hospitals, Ethiopia. Methods Institutional based cross-sectional study design was employed on 298 women from between April and May 2017. Study subjects were selected using systematic random sampling by considering the number of delivery. A structured questionnaire was used to collect the data. The data were coded and entered into Epi data version 3.1 and the analysis was carried out in a statistical package for social science versions 22. Descriptive statistics for each variable and binary logistic regression analysis with 95% CI was carried out. Results A total of 298 mothers were participated in the study with a response rate of 100%. The overall prevalence of caesarean section in this study was 38.3%. The multivariable analysis indicated that mother who had collage and above [AOR = 3.46 (95%CI; 1.2, 10.76)], giving birth in private health facility [AOR = 1.48 (95%CI; 1.84, 2.59)], and having risk factors [AOR = 2.86 (95%CI; 1.96, 3.42)], were some of the factors associated with caesarean section. Conclusion The finding of this study showed that the prevalence of caesarean section was higher in women who gave birth in private health facility, mothers having risk factors, and mothers having educational status of diploma and above. Therefore, identifying risky group during antenatal care follow-up and restraining numbers of caesarean section in private health facilities is essential steps to reduce high prevalence of caesarean section.


Introduction
Caesarean section is a surgical technique in which openings are made through a woman's abdomen and uterus to deliver her baby.
Caesarean section (C-section) may be indispensable when vaginal delivery might pose a danger to the mother or baby [1] caesarean section is one of the most significant lifesaving procedures that played a key role to decline maternal and perinatal morbidity and mortality rate. Caesarean section rates are high and continue to rise in industrialized countries, however, the impact of guidelines and recommendations in curbing their growth has been limited [2]. In the world now 1 in 5 women give birth by caesarean section. The average global rate of caesarean section (CS) is 18.6%, ranging from 6.0% to 27.2% in the least and more developed regions, respectively [3]. In 1985, representatives of a study group convened by the World Health Organization wrote, "there is no justification for any region to have caesarean section rates higher than 10-15% [4]. Despite this recommendation, evidences suggest that the rates of CS are high in developing countries and are increasing, with wide variation between countries and between regions of the same country [5]". In Ethiopia, overall institutional rate was 18%, which varied between 46% in the private sector and 15% in the public sector [6]. In Addis Ababa the rate of Caesarean section was increasing from 16%-22.9% as Ethiopian demographic health survey (EDHS) 2005-2014 report. It signifies the possibility of over-utilization of the service in the city [6][7][8]. In many developed countries, caesarean sections are increased and attention has focused on strategies to reduce its use due to the concern that higher caesarean section rates do not confer additional health gain but may increase maternal risk, have implications for future pregnancies and have resource implications for health service [9][10][11]. Caesarean sections conducted without clinical need can have adverse consequences for mothers and children. It increased the risk of adverse psychological sequelae, and problems in subsequent pregnancy, including uterine scar rupture greater risk of stillbirth and neonatal morbidity compared with vaginal delivery [12,13]. In low resources countries, like Ethiopia, on the other hand, lack of availability of, or access to, maternal health services and the corresponding underuse of caesarean sections (CS) are part of a web of factors predisposing to high maternal and perinatal morbidity and mortality [14]. Rationally, in such a background, there is concern that apparently inexorably rising rates of caesarean delivery have the potential to divert human and financial resources [15]. Currently there is much debate as to whether this surgical procedure should be performed for women without clear clinically acceptable indications [9,16,17]. American College of Obstetricians and Gynecologists, and the Society for Maternal Fetal Medicine, called for policy change to safely lower the rate of primary caesarean delivery [18]. In different literature, high caesarean section rates were found especially in the private sector [19]. Most previous studies were done on prevalence of caesarean section and focus only public health facility but there is inadequate research on factors associated with increase rate of caesarean section in both private and public health facility. Therefore it is important to understand the factors that drive the high caesarean section rates in order to put in place of interventions to reduce the rate. So the aim of this study was to assess prevalence and factors associated with caesarean section in Addis Ababa hospitals, Ethiopia.

Methods
Study area period: the study was conducted in Addis Ababa, the capital city of Ethiopia and it is located in the heart land of the country with a total area of 527 km 2 . This region has an estimated density Data collection procedure and quality control: data were collected by face to face interview using structured questionnaires and questionnaire checklist by review client chart. Seven diploma holder female midwives were recruited to collect the data, and three BSC holders nurse as supervisors from another area outside of study site. Before data collection data collectors and supervisors were trained on the objective, benefit of the study, individual's right, informed consent and techniques of the interview for one day. Before starting the actual data collection to assure the data quality high emphasis was given to designing data collection instrument, first the questionnaire was pre-tested on 30 (10%) of sample outside the study area. After pre-testing further adjustments to the data collection tool was made to improve clarity, understandability, and simplicity of the messages. All of the questionnaires were checked for completeness and accuracy before, during and after the period of data collection. Throughout the course of the data collection, interviewers were supervised, regular meetings were held between the data collectors and the principal investigator together in which problematic issues arising from interviews during the data collection and mistakes found during editing was discussed. The collected data was again reviewed and checked for completeness before data entry.
Data entry format template was prepared and programmed by the principal investigator. Thereafter, the multivariable logistic regression method was used. Pvalue of <0.05 and 95% confidence level was used as to declared statistical significance.  (Table 1).

Obstetric characteristics of respondents
Out of the total respondent more than half 169(56.7%) were gravid  Figure 1).

Factors associated with caesarean section
The multivariate logistic regression showed that.  (Table 3).

Discussion
Caesarean section is a life-saving procedure for both the mother and the baby. Delay in deciding for it may be detrimental for both. On the other hand, the premature and wrong decision may increase the maternal and fetal morbidity and mortality. The purpose of this study was to determine the prevalence of caesarean section and to identify factors leading to CS in Addis Ababa hospitals. The prevalence of women undertaking caesarean section in this study was 38.3%. This finding is consistent with studies conducted in Harare, Eastern part of Ethiopia 34% [20]. This study is also higher than the same study conducted in Yekatit 12 Hospital, Addis Ababa, Ethiopia 5.5% [21].
The discrepancy might be due to a large sample size of the previous study and lack of guide lines and recommendation to the lower high rate of Caesarean section. This finding is also higher than the same study which was conducted in Jimma Hospital; south-western Ethiopia showed that the rate of caesarean section was 8% [22]. The discrepancy might be due to study period difference and this study includes both private and public health facility but the previous study was only public hospitals. This finding is also higher than the same study which was conducted in Tikur Anbessa Teaching hospital, Ethiopia 10% [23]. The discrepancy might be due to study site difference, large sample size of previous study and study design difference. In this study the most common induction for caesarean was pervious caesarian section 27.2%, NRFHR 21%, post term pregnancy 15.6% and malpresentations/malposition 10.5% .This study is consistent with others study which was conducted in another part of Ethiopia [22][23][24]. According to this study respondents who were found in the age group of 20-29 were more likely utilize caesarean section than others. This finding was different from the same study which was conducted in Felegehiwot referral hospital, Bahir Dar, Ethiopia, showed that respondents who were found in the age group of 15-20 were more likely associated with caesarean section than others [24]. The finding of this study is higher than study conducted in Northwestern Nigeria which show that the prevalence of CS was 11.3% [25]. The discrepancy might be due to socio economic and cultural difference.

Conclusion
In this study, both obstetric and background Characteristics of mothers were the main reasons that leading to caesarean Section. An increase in the rates of caesarean section delivery is a burden on the health system. Unnecessary caesarean delivery also put a strain on family and may complicate maternal and child health. Therefore, the decision to perform a C-section delivery must be chosen carefully and should not be profit oriented. Early identification of risk age group, clear, compelling and well-supported decision of doctors to perform caesarean section, government intention to develop better health care infrastructure and strict vigil on the private health may help to reduce the high and increasing rate of caesarean delivery.