A case-control study of factors associated with caesarean sections at health facilities in Kabarole district, western Uganda, 2016

  • Pan African Medical Journal, Volume 29, Year 2018

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Study Justification:
– The study aimed to explore factors associated with caesarean section delivery in Kabarole district, Western Uganda.
– The World Health Organization recommends caesarean section rates of 10% to 15% at the population level, but there is limited access and utilization of caesarean section services in Uganda.
– Understanding the factors influencing caesarean section delivery can help improve access and utilization of the service.
Study Highlights:
– The study included 134 cases (women who had a caesarean section) and 134 controls (women who had a “normal” vaginal delivery).
– Factors associated with caesarean section delivery included having a previous caesarean section delivery and attending four or more antenatal care visits.
– Inadequate human resources, medicines, and supplies affected access to caesarean section services.
– Misconceptions about caesarean section delivery, such as negative branding of women as “lazy,” reduced acceptance and utilization of the service.
– Health system inadequacies and misconceptions contributed to the low access and utilization of caesarean section services.
Study Recommendations:
– Improve access to caesarean section services by addressing inadequate human resources, medicines, and supplies.
– Address misconceptions about caesarean section delivery through education and awareness campaigns.
– Strengthen antenatal care services to ensure women receive adequate care during pregnancy.
– Enhance the capacity of health facilities to provide caesarean section services, including training and infrastructure improvements.
Key Role Players:
– District Health Officer (DHO)
– Maternal and child health district in-charge
– Doctors, midwives, and nurses providing delivery services
– Managers of health facilities
– Higher degrees research and ethics committee of Makerere University School of Public Health
Cost Items for Planning Recommendations:
– Training programs for health workers
– Procurement of medicines and supplies
– Infrastructure improvements in health facilities
– Education and awareness campaigns
– Research and data analysis costs
– Monitoring and evaluation activities
Please note that the cost items provided are general examples and may vary depending on the specific context and requirements of the recommendations.

The strength of evidence for this abstract is 7 out of 10.
The evidence in the abstract is moderately strong, but there are some areas for improvement. The study design is a case-control study, which is a valid method for exploring factors associated with caesarean section delivery. The sample size calculation and selection process are clearly described, which enhances the reliability of the findings. The use of multivariable logistic regression analysis adds strength to the study. However, there are a few areas that could be improved. First, the abstract does not provide information on the representativeness of the sample, which could affect the generalizability of the findings. Second, the abstract does not mention any measures taken to control for confounding variables, which could impact the validity of the results. Third, while the abstract mentions the use of qualitative interviews with key informants, it does not provide any specific findings from this aspect of the study. To improve the strength of the evidence, it would be helpful to include information on the representativeness of the sample, the measures taken to control for confounding variables, and key findings from the qualitative interviews.

Introduction: World Health Organization estimates that the appropriate caesarean section rates should range from 10% to 15% at the population level. There is limited access and utilisation of caesarean section services in Uganda. This case-control study explored factors associated with caesarean section delivery, focusing on service-related and individual level factors. Methods: we interviewed 134 cases that had a caesarean section and 134 controls that had a “normal” vaginal delivery. The study was conducted at health facilities in Kabarole district during March to May 2016. Multivariable logistic regression was used to determine individual factors associated with caesarean sections, at a significance level of p 35 years) compared to the controls. The factors associated with caesarean section delivery were: having a previous caesarean section delivery (adjusted odds ratio (AOR): 4.5 CI: 2.22-9.0), attendance of four or more ANC visits (AOR: 2.0 CI: 1.04-3.83). Inadequate human resource, medicines and supplies affected access to the service. Misconceptions such as negative branding of women that have caesarean section deliveries as “lazy” reduced its acceptance thus low utilisation of the service. Conclusion: health system inadequacies and misconceptions about caesarean section delivery contributed to the low access and utilisation of the service.

Study design and setting: We conducted a case-control study at health facilities in Kabarole district, Western Uganda, during a 3 month period from March through May 2016. Caesarean section services in the district are offered only at the regional referral hospital and at two health centres in the public sector. While in the private sector, the service is offered at three hospitals. In our study, we included all the three public health facilities that provide caesarean section service and two randomly selected private facilities. Case-control definition: We defined a case as having a caesarean section delivery at the selected health facilities during March, April and May 2016. Controls were women that had a “normal” vaginal delivery at the same health facilities as the cases during the study period. A normal delivery was defined as a spontaneous vaginal delivery without the aid of instrument such as forceps or vacuum extraction. We excluded individuals who had been referred from neighbouring districts in both the case group and control group to avoid selection bias. Sample size calculation and sample selection: A two-stage sampling method was used in this study. At the first stage, we determined the sample size using James Schlesselman’s formula for unmatched case-control [20]. The odds ratio associated with exposure that would have sufficient public health importance was hypothesized at 2, using 95% confidence interval and power of 80% a sample size of 134 in the case group and 134 in the control group calculated. At the second stage of sampling, we purposefully included all the three public health facilities that provide caesarean section service in the district and also randomly sampled two private health facilities. We used probability proportionate to sample size sampling (PPS), to distribute the total sample size of 268 amongst the five-selected health facilities. Using the admission list in the maternity wards, study participants that met the inclusion criteria were consecutively sampled. For every case that was selected, a control was recruited. Key informant selection: We also conducted qualitative in-depth interviews with seven purposively selected key informants. These included doctors, midwives and nurses that provide delivery services at the health facilities visited. District health office leaders that included the District Health Officer (DHO) and district in-charge for maternal and child health were also interviewed. Variables: We assessed individual, maternal and health service related factors. Socio-demographic factors included maternal age, education level, marital status, employment status and socio-economic status. Factors related to maternal obstetric and health conditions were parity, multiple births, pre-existing medical conditions and previous caesarean section. Health services related factors were the distance to health facilities measured using geographical distance in kilometres from a place of residence to a health facility, prenatal care consultations (ANC), availability of health infrastructure, human resources, drugs and supplies. Data sources, measurement and quality control: Data were collected in the same way for individuals in the case and control groups. Socio-demographic and maternal information was obtained using face-to-face interviews aided by pre-coded, structured pre-tested questionnaires. Key informant (KI) interviews were also conducted on selected health workers aided by KI guides. The research team made daily visits to the hospitals and health centres to identify women that met the inclusion criteria. The interviews were conducted by trained research assistants with a medical background and fluent in the local languages spoken in the study area. Transcribed interviews were compared against recorded interviews to ensure the quality of qualitative data analysed. Data analysis: After descriptive statistical analysis, bivariable and multivariable analyses were conducted using logistic regression at a significance level of 0.05. We conducted the analysis using STATA statistical package version 12. Crude odds ratios (COR) and adjusted odds ratios (AOR) were obtained with their respective 95% confidence intervals (CI). Covariates that were significant at the bivariable level, with a p-value of less than 0.2 and those determined from literature to be associated with caesarean section were entered in the multivariable stepwise (backward and forward) logistic regression model. Hosmer and Lemeshow’s goodness of fit was applied to test the quality model. Previous caesarean section was the most significant variable in the model and was hence taken as the main predictor of caesarean section delivery. Interaction and confounding were tested with the main predictor (i.e. previous caesarean section) using stratified analysis. Confounding was further assessed by comparing the crude odds ratio with the adjusted odds ratio obtained using the Mantel Haenszel. A difference between crude and adjusted odds ratios greater than 10% showed a presence of confounding. Key informant recordings were transcribed and transcripts were uploaded into the qualitative analysis software MAXQDA version 12 and we analysed the data following the six steps of the thematic approach developed by Braun and Clarke [21]. Ethical approval: We sought ethical approval from the higher degrees research and ethics committee of the Makerere university school of public health, the District Health Officer (DHO) as well as managers of the respective health facilities where the research was conducted. Interviews were conducted after a written informed consent was obtained from the study participants.

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Based on the information provided, here are some potential recommendations for innovations to improve access to maternal health:

1. Strengthening Health System: Address the inadequate human resources, medicines, and supplies that affect access to caesarean section services. This could involve increasing the number of skilled healthcare providers, ensuring a consistent supply of essential medicines and equipment, and improving infrastructure in health facilities.

2. Education and Awareness: Address misconceptions and negative branding of women who have caesarean section deliveries. This could involve implementing educational campaigns to provide accurate information about caesarean sections, dispel myths and misconceptions, and promote acceptance and utilization of the service.

3. Telemedicine and Mobile Health: Explore the use of telemedicine and mobile health technologies to improve access to maternal health services, including caesarean sections. This could involve providing remote consultations, guidance, and support to healthcare providers in underserved areas, as well as facilitating communication and information-sharing between healthcare providers and pregnant women.

4. Community-Based Interventions: Implement community-based interventions to improve access to maternal health services. This could involve training and empowering community health workers to provide basic antenatal care, identify high-risk pregnancies, and refer women to appropriate healthcare facilities for caesarean sections when needed.

5. Financial Support: Address financial barriers to accessing caesarean section services. This could involve implementing or expanding health insurance schemes that cover maternal health services, providing subsidies or financial assistance for women who cannot afford the cost of caesarean sections, and exploring innovative financing models to make the services more affordable.

These recommendations are based on the findings and conclusions of the case-control study conducted in Kabarole district, Western Uganda, and aim to address the identified factors associated with low access and utilization of caesarean section services.
AI Innovations Description
The recommendation that can be used to develop an innovation to improve access to maternal health based on the study is to address the health system inadequacies and misconceptions about caesarean section delivery.

To address the health system inadequacies, it is important to focus on improving the availability of human resources, medicines, and supplies in health facilities that provide caesarean section services. This can be done by increasing the number of trained healthcare providers, ensuring a consistent supply of essential medicines and equipment, and improving the overall infrastructure of the facilities.

To address the misconceptions about caesarean section delivery, it is crucial to raise awareness and educate the community about the benefits and safety of the procedure. This can be achieved through community engagement programs, health education campaigns, and involving local leaders and influencers to promote positive messaging about caesarean sections.

Additionally, it is recommended to provide comprehensive antenatal care (ANC) services, including at least four ANC visits, as this was found to be associated with a higher likelihood of caesarean section delivery. Strengthening ANC services and ensuring that pregnant women have access to regular check-ups and necessary interventions can help identify and manage potential complications early on, reducing the need for emergency caesarean sections.

Overall, the innovation should focus on improving the availability and quality of caesarean section services, addressing misconceptions, and promoting comprehensive ANC to improve access to maternal health.
AI Innovations Methodology
Based on the provided information, here are some potential recommendations for improving access to maternal health:

1. Increase availability of caesarean section services: Expand the number of health facilities that offer caesarean section services, particularly in areas with limited access.

2. Improve human resource allocation: Address the inadequate human resource issue by recruiting and training more doctors, midwives, and nurses to provide delivery services.

3. Enhance availability of medicines and supplies: Ensure that health facilities have an adequate supply of medicines and necessary equipment for caesarean section procedures.

4. Address misconceptions and stigma: Conduct awareness campaigns to address misconceptions about caesarean section deliveries, such as the negative branding of women as “lazy.” Educate communities about the benefits and safety of caesarean sections.

To simulate the impact of these recommendations on improving access to maternal health, a methodology could include the following steps:

1. Define the target population: Determine the specific population that will be affected by the recommendations, such as pregnant women in a particular region or district.

2. Collect baseline data: Gather data on the current access to maternal health services, including the number of caesarean section deliveries, availability of services, and any existing barriers.

3. Develop a simulation model: Create a mathematical or statistical model that incorporates the factors influencing access to maternal health, such as distance to health facilities, availability of services, and socio-economic factors. This model should be able to simulate the impact of the recommendations on improving access.

4. Input data and parameters: Input the baseline data and parameters into the simulation model, including the current availability of caesarean section services, human resource allocation, availability of medicines and supplies, and community perceptions.

5. Simulate scenarios: Run the simulation model with different scenarios that reflect the implementation of the recommendations. For example, simulate the impact of increasing the number of health facilities offering caesarean section services or improving human resource allocation.

6. Analyze results: Analyze the simulation results to determine the potential impact of the recommendations on improving access to maternal health. This could include measures such as the increase in the number of caesarean section deliveries, reduction in distance to health facilities, or improvement in community perceptions.

7. Validate and refine the model: Validate the simulation model by comparing the simulated results with real-world data, if available. Refine the model based on feedback and further data analysis.

8. Communicate findings: Present the findings of the simulation study to relevant stakeholders, such as policymakers, healthcare providers, and community leaders. Use the results to advocate for the implementation of the recommendations and inform decision-making processes.

It is important to note that the methodology for simulating the impact of recommendations may vary depending on the specific context and available data.


Statistics:
Citations: 1
Identifiers:
DOI: 10.11604/pamj.2018.29.179.14870
Research Areas:
Health System and Policy, Maternal Access, Maternal and Child Health, Quality of Care, Social Determinants, Technology and Innovations, Workforce
Study Countries:
Uganda
Study Design:
Case-Control Study, Cross Sectional Study, randomised-control-trial
Study Approach:
Mixed-methods, Qualitative, Quantitative
Participants Gender:
Female
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