Menu
Menu
Menu
Menu
Background In order to meet the Sustainable Development Goal to decrease maternal mortality, increased access to obstetric interventions such as Caesarean sections (CS) is of critical importance. As a result of women’s limited access to routine and emergency obstetric services in Nigeria, the country is a major contributor to the global burden of maternal mortality. In this analysis, we aim to establish rates of CS and determine socioeconomic or medical risk factors associated with having a CS in Enugu, southeast Nigeria. Methods Data for this study originated from the Healthy Beginning Initiative study. Participant characteristics were obtained from 2300 women at baseline via a semi-structured questionnaire. Only women between the ages of 17-45 who had singleton deliveries were retained for this analysis. Post-delivery questionnaires were used to ascertain mode-of-delivery. Crude and adjusted logistic regressions with Caesarean as the main outcome are presented. Results In this sample, 7.22% women had a CS. Compared to women who lived in an urban setting, those who lived in a rural setting had a significant reduction in the odds of having a CS (aOR: 0.58; 0.38-0.89). Significantly higher odds of having a CS were seen among those with high peripheral malaria parasitemia compared to those with low parasitemia (aOR: 1.54; 1.04-2.28) Conclusion This study revealed that contrary to the increasing trend in use of CS in low-income countries, women in this region of Nigeria had limited access to this intervention. Increasing age and socioeconomic proxies for income and access to care (e.g., having a tertiary-level education, full-time employment, and urban residence) were shown to be key determinants of access to CS. Further research is needed to ascertain the obstetric conditions under which women in this region receive CS, and to further elucidate the role of socioeconomic factors in accessing CS.
Enugu State is in the southeastern part of Nigeria. With a population between 3–6 million, according the state government, Enugu has predominately rural agrarian households with some urban centers [29]. Data for this study were derived from the Healthy Beginning Initiative study (HBI), which has been described in detail elsewhere [30]. Briefly, the parent study was a two-arm randomized cluster trial aimed to assess rates of HIV testing. HBI used congregation-based sampling to recruit pregnant women and their partners in 40 churches from four dioceses (the Anglican Diocese of Enugu, the Catholic Diocese of Enugu, the Anglican Diocese of Oji-River, and the Catholic Diocese of Agwu). Women who were self-identified as pregnant were included in the study. Recruitment occurred at the level of the churches and participants (in that order), while randomization occurred only at the church level—that is, churches were randomly assigned to either the intervention or control groups. The intervention group participated in educational games about healthy pregnancy habits in addition to HIV acquisition modes, and effective prevention of mother-to-child transmission. They were also offered free prenatal care in the form of blood samples taken on-site to test for HIV, hemoglobin, malaria, hepatitis B, sickle cell gene, and syphilis. Women who tested positive for HIV were linked to local HIV care. Women in the control group were encouraged to attend prenatal care through nearby health facilities and were also referred to the health facility for testing. The research team maintained direct contact with health facilities to confirm HIV testing and prevention of mother-to-child transmission completion. Women in both the control and intervention groups completed a post-delivery questionnaire, which was available every 2 to 3 months at church. Maternal mortality was not ascertained in the parent study. In Nigeria, approximately 35% of pregnant women deliver at a healthcare facility; therefore, a community-based sampling technique was employed to obtain a more representative sample of pregnant women [31]. Also, because pregnant women were recruited from churches in Enugu State, Nigeria, a more representative sample of pregnant women was expected as the population is more than 95% Christian and church attendance approaches 90% [30]. Pregnant women interested in the study were asked to read and sign a consent form in either English or the local language, Ibo. If the participant was illiterate, the consent form was read aloud to her in the local language; then the participant affixed her thumb print as an indication of her consent to participate in the study [30]. Demographic characteristics of participants were obtained at baseline via a semi-structured questionnaire [30]. Trained research staff and church-based health advisors administered this questionnaire written at a 6th grade reading level. Participants had the option of reading the survey themselves or having study personnel read to them. Because of inherent risks associated with having multiples (i.e. twins, triplets etc.), only women between the ages of 17–45 at baseline, who had singleton deliveries, were retained for this analysis. The length of pregnancy at baseline was not ascertained. Participants remained in the study until post-delivery. Post-delivery questionnaires were used to ascertain the mode of delivery, i.e., CS or vaginal birth, and singleton or multiple deliveries. Gravidity was dichotomized as primigravida and multigravida. Overall 76.6% (n = 2300) of participants who gave informed consent answered questions regarding their mode of delivery (Control n = 1042; Intervention n = 1258). Only women who answered the question regarding mode of delivery on the post-delivery questionnaire were retained for the analysis described in Table 1. However, not all women had complete data on socioeconomic and comorbid conditions; therefore, only 1,680 women were retained for the analysis described in Table 2. The study took place from January 2013 to August 2014. Notes: * Significance based on Pearson’s Chi-square for Fisher’s Exact p<0.05 significant aIndicates p-value based on Fishers Exact Notes: a. Models adjusted for other variables in the table *Indicates significance at p<0.05 Variables assessed by laboratory tests were hemoglobin, malaria parasitemia, human immunodeficiency virus (HIV), and sickle cell disease/trait (SCD). Participants were tested either at baseline—following recruitment into the study—or during their prenatal visits, whereupon records were obtained from the participant’s corresponding hospital. Hemoglobin was assessed using the standard cyanmethemoglobin method [32]. WHO guidelines for anemia were employed [33], and pregnant woman were classified as anemic if they had a hemoglobin level below 11g/dl. Peripheral parasitemia levels were assessed using the malaria plus system [34]. Because results indicated that 99% of this sample showed malaria parasitemia, malaria parasitemia was reclassified as low and high based on the malaria plus system with those in the 0 and + group classified as low parasitemia and those in the ++ and +++ groups classified as high parasitemia. HIV testing was performed using the Rapid Testing Serial Algorithm II [35]. If both tests were positive for HIV, the individual was considered HIV positive; if both tests were negative, the individual was considered HIV negative. When the tests showed conflicting results, they were both repeated and the results were read by another technician, who did not know the results of the first series of tests. EDTA-treated venous blood samples were used to screen for SCD. To decrease the chances of a false positive or negative of SCD, each sample was tested twice. If incongruent results occurred, the test was rerun. Univariate analyses were based on Pearson's Chi-square test for comparison of proportions for all variables. Fisher's exact tests for contingency tables were used to test for significance in proportions when the expected cell counts were less than 5. Chi-square analyses with p<0.10 were further analyzed using crude and adjusted logistic regression with CS as the main outcome. Having a CS in previous pregnancies is known to predict current CS; therefore, gravida was included in logistic regression models. Because no information was collected specifically regarding previous CS, a sensitivity analysis was performed among those experiencing their first pregnancy. Statistical significance was set at p<0.05. An adjusted trend in the Odds Ratio (OR) was conducted to determine whether there was an increasing trend in the odds of having a CS as a participant’s age and education level increased by using the “tabodds” function in Stata [Stata Corporation, College Station, TX]. Participant’s age was recorded during pregnancy on the baseline survey and was categorized as 17–24, 25–34, and 35–45. Only one women who had a CS had no formal education; therefore, education was categorized as none/primary, secondary and tertiary and above. Age and education were retained as categorical variables for inclusion in multivariable models. Birthweight was collected as part of the parent study; however, because it was self-reported and most newborns were not weighed at birth, birthweight was not deemed reliable. Therefore, birthweight was not included in this analysis. A power analysis was conducted in the parent study [30]; because mode of delivery was not the main outcome of the trial, no additional power analyses were completed before data collection. No difference was observed in mode of delivery between the control and intervention groups (CS intervention group 7.20%, control group 8.54%; mode of delivery chi-square: p = 0.27). Therefore, data was not restricted to only the control group and all analyses treated the sample as a cohort. Data analyses were conducted using Stata version 12.0. The parent study was approved by the Institutional Review Board of the University of Nevada, Reno, and the Nigerian National Health Research Ethics Committee. This secondary data-analysis was appraised by Research Office of the Mel and Enid Zuckerman College of Public Health, and was considered exempt. This research was funded by the Eunice Kennedy Shriver National Institute of Child Health and Human Development (NICHD), the National Institute of Mental Health (NIMH) and the President’s Emergency Plan for AIDS Relief (PEPFAR) under award number R01HD075050 to Echezona Ezeanolue, MD.
N/A
