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Background: Caesarean section (CS) can prevent maternal or fetal complications. Sub-Saharan Africa has the lowest CS levels in the world but large variations are seen between and within countries. The tertiary hospital, Kilimanjaro Christian Medical Centre (KCMC) in Tanzania has had a high level of CS over years. The aim of this study was to examine trends in the socio-demographic background of babies born at KCMC from year 2000 to 2013, and trends in the CS percentage, and to identify socio-demographic factors associated with CS at KCMC during this period. Methods: This is a registry-based study. The analyses were limited to singletons born by women from Moshi urban and rural districts. The Chi square test for linear trend was used to examine trends in the CS percentage and trends in the socio-demographic background of the baby. The association between different socio-demographic factors and CS was assessed using logistic regression. The analyses were stratified by the mother’s residence. Results: The educational level of mothers and fathers and the age of the mothers of singletons born at KCMC increased significantly from year 2000 to 2013 both among urban and rural residents. Among 29,752 singletons, the overall CS percentage was 28.9%, and there was no clear trend in the overall CS percentage between 2000 and 2013. In the multivariable model, factors associated with higher odds of CS were: having been referred for delivery, maternal age above 25 and no- or primary education level of the baby’s father. Among rural mothers, no- or primary education, being from the Pare tribe and para 2-3 were also associated with higher odds of CS. Being from the Chagga tribe and high parity were associated with lower odds of CS compared to other tribes and parity 1. Conclusions: The CS percentage remained high but stable over time. Large variations in CS levels between different socio-demographic groups were observed. The educational level of the parents of babies born at KCMC increased over time, possibly reflecting persistent inequitable access to the services offered at the hospital.
This is a registry based study. The medical birth registry at KCMC was established in 1999 in collaboration with the University of Bergen, Norway. It has been in operation since July 2000 [31]. Information on birth outcome, delivery mode, obstetric history as well as socio- demographic factors is recorded in the registry [32]. Information is recorded by specially trained nurse-midwives using a questionnaire designed specifically for this purpose. The mothers are interviewed soon after recovery from the birth, usually within the first 24 hours, but later if complications occur. Supplementary information is collected from case files. Registration of this information is done every day, including weekends and holidays. A secretary then enters the data into an electronic file. Quality assurance of the birth registry has consisted of periodic instruction sessions [31]. The birth registry only registers deliveries at KCMC and includes both stillbirths and live births. The United Republic of Tanzania is the largest country in East Africa with about 45 million inhabitants (2012). Almost 75% of the inhabitants live in rural areas [33]. KCMC is one of four zonal/tertiary hospitals in Tanzania [34]. It is operated as a private/public partnership and located in Moshi town in the Kilimanjaro region. The region has more than 1.6 million inhabitants. Moshi rural district has a total population of 466,737 inhabitants whereas Moshi urban district has a population count of 184,292 [33]. KCMC has approximately 3300 deliveries per year, and the obstetric ward at KCMC receives high risk cases from seven regions in northern Tanzania and from some Kenyan districts [35]. In total the hospital thus serves more than 13 million people [36]. About 50% of the birthing women at KCMC come from Moshi urban district as they come for ordinary deliveries too [26]. About 20% of the birthing women come from Moshi rural district. The regional hospital, Mawenzi, also located in Moshi town, is supposed to offer emergency obstetric care for free, CS included, but the operation capacity has been relatively poor for a long time, and since December 2010, no CS have been conducted because the operation theatre closed. Thus KCMC has been the only referral institution that has offered CS after 2010 in Moshi, apart from private hospitals with substantial higher costs. About 88% of the women give birth in a health facility in Kilimanjaro [27]. The direct cost of normal delivery and CS at KCMC has gradually increased. Before 2005 the minimum price for CS was 20,000 TZS (=25.3 USD based on 01.01.2000 rates) but in 2005 a “cost sharing” policy was introduced and the out-of-pocket payment for CS was raised to a minimum of 50,000 TZS (=47.2 USD based on 01.01.2005 rates). It further increased to 100,000 TZS in 2011 (=58.4 USD based on 01.12.2011 rates) [37]. In addition to this the patients pay a per night fee, and pay for drugs and other costs associated with the hospital stay. There were a total of 45,871 births at KCMC in the period July 2000 to June 2013 of which 31,287 of the deliveries were among women residing in Moshi urban and Moshi rural districts. The majority of the deliveries, 29,752 (95.1%), were singleton births. We restricted the analyses to singletons born by women from the two Moshi districts (urban and rural) at KCMC hospital in the period July 2000 to June 2013. The main outcome variable was CS. The independent variables included education of the mother and the father, age of the mother, tribe of the mother, marital status of the mother, referral status, parity and year of delivery. Mother’s and father’s education completed were categorized into two categories: ‘no education/primary education’ (0–7 years) and ‘secondary/higher education’ (8 years or more). The variable maternal tribe was recoded as: ‘Chagga’, ‘Pare’ (which were the two most common), and ‘Other’, including more than 120 different tribes. Marital status was dichotomized as ‘married’ (i.e. monogamous and polygamous marriages or cohabitation) and ‘not married’ (i.e. separated/divorced, widowed or never-married). Age of the mother was included as a categorical variable with 4 categories: ‘13-17’ years, ‘18-25’ years, ‘26-35’ years and ‘36 to 47’ years. Women less than 13 years or more than 47 years of age were excluded in analyses including age as a variable. Parity was categorized in four: ‘para 1’, ‘para 2-3’, ‘para 4-6’ and ‘para 7+’. Referral status was divided into two categories: ‘medically referred’ (i.e. referred by qualified health personal for medical reasons) and ‘not referred’. Time of birth was included in most of the analyses as a continuous variable (called ‘year of birth’). However, in some of the analyses, time of birth was included as a categorical variable (called ‘time period’), with the categories representing three time periods associated with different levels of user fees at KCMC: Period 1: July 2000 to December 2004; period 2: January 2005 to November 2011; and period 3: December 2011 to June 2013. The data was analyzed using Statistical Package for Social Science (SPSS) version 20. All the analyses were stratified by mother’s residence (urban/rural). Frequency tables and graphs were used to describe changes in all births and CS deliveries year by year. Changes over time in the socio-demographic background of the babies born (all deliveries and CS) were tested using Chi square test for trend for each of the socio-demographic factors (with time both as a categorical variable with three time periods and as a integer variable: ‘year of birth’). Trends in the level of CS were examined using the Chi square test for trend, both overall and stratified by referral status. The likelihood of CS during the whole period was assessed using logistic regression. We started with bivariate analyses. We then developed models with interaction terms between each of the independent variables (socio-demographic factors and referral status) and time of birth as continuous variable. Finally, we developed a multivariable model with all the independent variables and significant interaction terms. Odds ratios with 95% confidence intervals were calculated. Babies with missing data on any of the independent variables (referral status, father’s and mother’s education level, marital status, mother’s tribe, mother’s age and parity) were excluded from the multivariable analyses. No person-identifiable information is available in the electronic birth registry handled by the researchers. Participation is based on verbal informed consent from the mothers. The birth registry at KCMC obtained ethical clearance from the Tanzania Ministry of Health, Commission for Science and Technology, from the KCM College and from the Norwegian National Ethics committee in 1999 [32]. The protocol for this study obtained ethical approval from Kilimanjaro Christian Medical University College of Tumaini University Makumira, in December 2013.
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