Maternal and perinatal outcome after previous caesarean section in rural Rwanda

BMC Pregnancy and Childbirth, Volume 17, No. 1, Year 2017

Interpretation

Background: Offering a trial of labor (ToL) after previous caesarean section (CS) is an important strategy to reduce short- and long-term morbidity associated with repeated CS. We compared maternal and perinatal outcomes between ToL and elective repeat caesarean section (ERCS) at a district hospital in rural Rwanda. Methods: Audit of women’s records with one prior CS who delivered at Ruhengeri district hospital in Rwanda between June 2013 and December 2014. Results: Out of 4131 women who came for delivery, 435 (11%) had scarred uteri. ToL, which often started at home or at health centers without appropriate counseling, occurred in 297/435 women (68.3%), while 138 women (31.7%) delivered by ERCS. ToL was successful in 134/297 (45.1%) women. There were no maternal deaths. Twenty-eight out of all 435 women with a scarred uterus (6.4%) sustained severe acute maternal morbidity (puerperal sepsis, postpartum hemorrhage, uterine rupture), which was higher in women with ToL (n=23, 7.7%) compared with women who had an ERCS (n=5, 3.6%): adjusted odds ration (aOR) 1.4 (95% CI 1.2-5.4). There was no difference in neonatal admissions between women who underwent ToL (n=64/297; 21.5%) and those who delivered by ERCS (n=35/138; 25.4%: aOR 0.8; CI 0.5-1.6). The majority of admissions were due to perinatal asphyxia that occurred more often in infants whose mothers underwent ToL (n=40, 13.4%) compared to those who delivered by ERCS (n=15, 10.9%: aOR 1.9; CI 1.6-3.6). Perinatal mortality was similar among infants whose mothers had ToL (n=8; 27/1000 ToLs) and infants whose mothers underwent ERCS (n=4; 29/1000 ERCSs). Conclusions: A considerable proportion of women delivering at a rural Rwandan hospital had scarred uteri. Severe acute maternal morbidity was higher in the ToL group, perinatal mortality did not differ. ToL took place under suboptimal conditions: access for women with scarred uteri into a facility with 24-h surgery should be guaranteed to increase the safety of ToL. We conducted a retrospective cohort study of all women who had caesarean section (CS) in a previous pregnancy with a singleton infant in cephalic presentation at 36 weeks of gestation or higher in the pregnancy of study. Data were extracted from a large sample of pregnant women who were admitted for delivery at Ruhengeri maternity ward in Musanze district, Rwanda, between June 2013 and December 2014 [17]. The hospital acts as a provincial referral hospital for high-risk obstetric cases from health centers and district hospitals in the northern province. It conducts about 3500 deliveries annually, with perinatal and maternal mortality rates of 31 per 1000 live birth and 325 per 100,000 live births respectively [17]. Blood for transfusion was supplied by the regional blood bank located next to the hospital. A clinician capable of performing CS is permanently available. Although some people have private health insurance, most of the general population use community-based health insurance with an annual fee contribution of RWF 3000 (US$4.5), plus a 10% co-payment for each episode of illness. In case of shortages of drug supplies, patients are requested to procure missing items from private pharmacies. We identified potential candidates for ToL and ERCS by a process of elimination (Fig. (Fig.1).1). Women presenting in labor with a cervical dilatation of at least 3 cm were classified as having undergone ToL. Women with absolute contraindications to vaginal delivery in our setting (e.g. multiple pregnancy, non-cephalic presentation, intrauterine growth retardation, prior myomectomy and genital herpes) underwent ERCS. We also excluded women presenting with less than 3 cm dilatation due to the impossibility to distinguish between failed ToL and ERCS. Successful ToL was defined as vaginal delivery following ToL. Flow chart on mode of deliveries among women underwent trial of Labor and elective repeat caesarean section During labor, women were monitored using a partogram including regular auscultation of the fetal heart by fetoscope at least once every 30 min and regular prompting for vaginal bleeding, uterine tenderness and staining of liquor. Augmentation of labor was done by artificially rupturing the membranes, but in this specific setting oxytocic drugs were not used for fear of uterine rupture. Induction of labor was not performed. ToL was terminated if the partogram crossed the action line, if tenderness occurred at the site of the uterine scar, or in case of signs of fetal distress, the latter defined as the presence of meconium stained liquor, an irregular fetal heart beat or a heart beat of less than 120 or more than 160. Term neonates with low 5 min APGAR Score or stated as low APGAR Score but non-quantified who were encephalopathic (abnormal posture, unconscious, abnormal tone or seizures) were given a diagnosis of perinatal asphyxia. Mother and newborn were observed for at least 24 h following vaginal delivery while those women who delivered by CS and did not have complications were discharged on the fourth day after surgery. Data were collected from medical records by two trained research assistants who were supervised by the principal investigator. For every case, information was collected regarding socio-demographic characteristics, medical history, antenatal care attendance (ANC), medical conditions diagnosed before or during current pregnancy, details of previous CS, mode of delivery, and maternal and perinatal outcome including complications. Maternal and perinatal outcomes were compared between women who underwent ToL and ERCS. All data were entered into Microsoft Excel and transferred to STATA version 13 for analysis. Initial comparisons were done using the chi-square test for categorical data and Student’s t-test for continuous data. Maternal age, marital status, four or more ANC visits, gestational age, previous indications for CS and inter delivery interval were examined for interaction and confounding. Our analysis revealed no significant interaction among these covariates. Multivariate logistic regression analysis was used to control for simultaneous effects of covariates. Adjusted odds ratios and 95% confidence intervals were derived from the regression coefficients.

AI Digest

Study Justification:

– The study aims to compare the outcomes of trial of labor (ToL) and elective repeat caesarean section (ERCS) for women with a previous caesarean section (CS) in a rural setting in Rwanda.
– This study is important because offering ToL after CS can reduce the morbidity associated with repeated CS, but there is limited data on the outcomes in rural areas.
– The findings of this study can inform healthcare providers and policymakers on the safety and effectiveness of ToL in this context.

Study Highlights:

– Out of 4,131 women who came for delivery, 435 (11%) had scarred uteri from a previous CS.
– 68.3% of women with scarred uteri underwent ToL, while 31.7% had ERCS.
– ToL was successful in 45.1% of cases.
– Severe acute maternal morbidity was higher in the ToL group compared to the ERCS group.
– There was no difference in neonatal admissions between the two groups, but perinatal asphyxia occurred more often in infants whose mothers underwent ToL.
– Perinatal mortality was similar between the two groups.

Recommendations:

– Access for women with scarred uteri to a facility with 24-hour surgery should be guaranteed to increase the safety of ToL.
– Appropriate counseling should be provided to women considering ToL to ensure they make informed decisions.
– Measures should be taken to reduce the occurrence of severe acute maternal morbidity and perinatal asphyxia in women undergoing ToL.

Key Role Players:

– Healthcare providers: Obstetricians, midwives, nurses, and other medical staff involved in maternal and perinatal care.
– Policy makers: Government officials, health ministry representatives, and other decision-makers responsible for healthcare policies and resource allocation.
– Community leaders: Local leaders who can help promote awareness and education about the benefits and risks of ToL.

Cost Items for Planning Recommendations:

– Facility upgrades: Ensuring that a facility has 24-hour surgery capabilities may require investments in infrastructure, equipment, and staffing.
– Training and education: Healthcare providers may need additional training and education on counseling women about ToL and managing complications.
– Outreach and awareness campaigns: Funds may be needed to conduct community outreach programs to educate women and their families about the benefits and risks of ToL.
– Monitoring and evaluation: Resources may be required to establish systems for monitoring and evaluating the outcomes of ToL and implementing quality improvement measures.
Please note that the cost items provided are general categories and the actual cost will depend on the specific context and requirements of the recommendations.

Strength of Evidence

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 retrospective cohort study, which provides valuable information but is not as robust as a randomized controlled trial. The sample size is relatively large, which increases the generalizability of the findings. However, the study could benefit from a more detailed description of the inclusion and exclusion criteria for the participants. Additionally, the abstract could provide more information on the statistical methods used for analysis. To improve the strength of the evidence, future studies could consider conducting a randomized controlled trial and providing more detailed information on the study design and statistical analysis methods.

Abstract

We conducted a retrospective cohort study of all women who had caesarean section (CS) in a previous pregnancy with a singleton infant in cephalic presentation at 36 weeks of gestation or higher in the pregnancy of study. Data were extracted from a large sample of pregnant women who were admitted for delivery at Ruhengeri maternity ward in Musanze district, Rwanda, between June 2013 and December 2014 [17]. The hospital acts as a provincial referral hospital for high-risk obstetric cases from health centers and district hospitals in the northern province. It conducts about 3500 deliveries annually, with perinatal and maternal mortality rates of 31 per 1000 live birth and 325 per 100,000 live births respectively [17]. Blood for transfusion was supplied by the regional blood bank located next to the hospital. A clinician capable of performing CS is permanently available. Although some people have private health insurance, most of the general population use community-based health insurance with an annual fee contribution of RWF 3000 (US$4.5), plus a 10% co-payment for each episode of illness. In case of shortages of drug supplies, patients are requested to procure missing items from private pharmacies. We identified potential candidates for ToL and ERCS by a process of elimination (Fig. (Fig.1).1). Women presenting in labor with a cervical dilatation of at least 3 cm were classified as having undergone ToL. Women with absolute contraindications to vaginal delivery in our setting (e.g. multiple pregnancy, non-cephalic presentation, intrauterine growth retardation, prior myomectomy and genital herpes) underwent ERCS. We also excluded women presenting with less than 3 cm dilatation due to the impossibility to distinguish between failed ToL and ERCS. Successful ToL was defined as vaginal delivery following ToL. Flow chart on mode of deliveries among women underwent trial of Labor and elective repeat caesarean section During labor, women were monitored using a partogram including regular auscultation of the fetal heart by fetoscope at least once every 30 min and regular prompting for vaginal bleeding, uterine tenderness and staining of liquor. Augmentation of labor was done by artificially rupturing the membranes, but in this specific setting oxytocic drugs were not used for fear of uterine rupture. Induction of labor was not performed. ToL was terminated if the partogram crossed the action line, if tenderness occurred at the site of the uterine scar, or in case of signs of fetal distress, the latter defined as the presence of meconium stained liquor, an irregular fetal heart beat or a heart beat of less than 120 or more than 160. Term neonates with low 5 min APGAR Score or stated as low APGAR Score but non-quantified who were encephalopathic (abnormal posture, unconscious, abnormal tone or seizures) were given a diagnosis of perinatal asphyxia. Mother and newborn were observed for at least 24 h following vaginal delivery while those women who delivered by CS and did not have complications were discharged on the fourth day after surgery. Data were collected from medical records by two trained research assistants who were supervised by the principal investigator. For every case, information was collected regarding socio-demographic characteristics, medical history, antenatal care attendance (ANC), medical conditions diagnosed before or during current pregnancy, details of previous CS, mode of delivery, and maternal and perinatal outcome including complications. Maternal and perinatal outcomes were compared between women who underwent ToL and ERCS. All data were entered into Microsoft Excel and transferred to STATA version 13 for analysis. Initial comparisons were done using the chi-square test for categorical data and Student’s t-test for continuous data. Maternal age, marital status, four or more ANC visits, gestational age, previous indications for CS and inter delivery interval were examined for interaction and confounding. Our analysis revealed no significant interaction among these covariates. Multivariate logistic regression analysis was used to control for simultaneous effects of covariates. Adjusted odds ratios and 95% confidence intervals were derived from the regression coefficients.

Materials

N/A

Innovations

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

1. Implementing comprehensive counseling: Provide appropriate counseling to women with scarred uteri regarding the risks and benefits of trial of labor (ToL) and elective repeat caesarean section (ERCS). This would ensure that women are well-informed and can make informed decisions about their delivery method.

2. Improving access to facilities with 24-hour surgery: Guarantee access for women with scarred uteri to facilities that have 24-hour surgery capabilities. This would increase the safety of ToL by ensuring that emergency interventions can be performed promptly if needed.

3. Strengthening referral systems: Enhance the referral systems between health centers, district hospitals, and provincial referral hospitals. This would ensure that women with high-risk pregnancies or complications can be promptly referred to higher-level facilities where they can receive appropriate care.

4. Enhancing monitoring during labor: Improve the monitoring of women during labor, including regular auscultation of the fetal heart, monitoring for vaginal bleeding, uterine tenderness, and staining of liquor. This would help identify any signs of fetal distress or complications early on.

5. Providing access to necessary medications and supplies: Ensure that facilities have an adequate supply of necessary medications and supplies, including blood for transfusion. This would prevent delays in care due to shortages and improve the overall quality of maternal health services.

6. Strengthening community-based health insurance: Enhance community-based health insurance programs by addressing any gaps in coverage and ensuring that the annual fee contribution is affordable for all women. This would help increase access to maternal health services for women who rely on these insurance programs.

7. Improving data collection and analysis: Enhance the collection and analysis of data on maternal and perinatal outcomes to identify areas for improvement and monitor the impact of interventions. This would help guide future efforts to improve access to maternal health.

It is important to note that these recommendations are based on the specific context and findings of the study mentioned. Implementing these innovations would require careful planning, collaboration between stakeholders, and ongoing monitoring and evaluation to ensure their effectiveness.

AI Innovations Description

Based on the information provided, the recommendation to improve access to maternal health and develop innovation is to ensure that women with scarred uteri have access to a facility with 24-hour surgery. This will increase the safety of offering a trial of labor (ToL) after previous caesarean section (CS). Currently, ToL often starts at home or at health centers without appropriate counseling, leading to suboptimal conditions for the procedure. By guaranteeing access to a facility with 24-hour surgery, women with scarred uteri can receive proper care and support during ToL, reducing the risk of severe acute maternal morbidity and improving maternal and perinatal outcomes.

AI Innovations Methodology

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

1. Strengthening Counseling Services: Provide comprehensive and accurate counseling to women with scarred uteri regarding the risks and benefits of trial of labor (ToL) and elective repeat caesarean section (ERCS). This should include information on potential complications, success rates, and the importance of delivering in a facility with 24-hour surgery.

2. Improving Facility Access: Ensure that women with scarred uteri have guaranteed access to a facility with 24-hour surgery. This may involve improving transportation services, establishing referral systems, and increasing the number of facilities equipped to handle high-risk obstetric cases.

3. Enhancing Monitoring and Support during ToL: Implement protocols for regular monitoring of women undergoing ToL, including fetal heart rate monitoring, assessment of uterine tenderness, and prompt intervention in case of signs of fetal distress. This will help ensure timely identification and management of complications.

4. Strengthening Perinatal Care: Improve perinatal care by providing training to healthcare providers on neonatal resuscitation and management of perinatal asphyxia. This will help reduce the incidence of perinatal asphyxia and improve neonatal outcomes.

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

1. Data Collection: Collect data on the current access to maternal health services, including the number of women with scarred uteri, the proportion undergoing ToL, and the outcomes of ToL and ERCS.

2. Define Key Indicators: Identify key indicators to measure the impact of the recommendations, such as the proportion of women with scarred uteri accessing a facility with 24-hour surgery, the success rate of ToL, and the incidence of severe acute maternal morbidity and perinatal asphyxia.

3. Baseline Analysis: Analyze the baseline data to establish the current situation and identify areas for improvement.

4. Simulate Scenarios: Use modeling techniques to simulate different scenarios based on the implementation of the recommendations. This could involve adjusting the proportion of women accessing a facility with 24-hour surgery, the success rate of ToL, and the incidence of complications.

5. Impact Assessment: Assess the impact of each scenario on the key indicators identified in step 2. This could be done through statistical analysis, comparing the outcomes between different scenarios.

6. Sensitivity Analysis: Conduct sensitivity analysis to test the robustness of the results and assess the potential variability in the impact of the recommendations.

7. Recommendations and Implementation: Based on the findings of the simulation, make recommendations for the implementation of specific interventions to improve access to maternal health. These recommendations should be evidence-based and consider the local context and resources available.

8. Monitoring and Evaluation: Continuously monitor and evaluate the implementation of the recommendations to assess their effectiveness and make any necessary adjustments.

By following this methodology, policymakers and healthcare providers can gain insights into the potential impact of different interventions on improving access to maternal health and make informed decisions to prioritize and implement the most effective strategies.

Author

Dima Health

Statistics:

Citations: 10

Identifiers:

DOI: 10.1186/s12884-017-1467-5

Research Areas:

Community Interventions, Health System and Policy, Maternal Access, Maternal and Child Health, Sexual and Reproductive Health, Social Determinants

Study Countries:

Rwanda

Study Design:

Cohort Study, Cross Sectional Study

Study Approach:

Quantitative

Participants Gender:

Female