Individual and institutional determinants of caesarean section in referral hospitals in Senegal and Mali: a cross-sectional epidemiological survey

Abstract

Background: Two years after implementing the free-CS policy, we assessed the non-financial factors associated with caesarean section (CS) in women managed by referral hospitals in Senegal and Mali.

Methods: We conducted a cross-sectional survey nested in a cluster trial (QUARITE trial) in 41 referral hospitals in Senegal and Mali (10/01/2007-10/01/2008). Data were collected regarding women's characteristics and on available institutional resources. Individual and institutional factors independently associated with emergency (before labour), intrapartum and elective CS were determined using a hierarchical logistic mixed model.

Results: Among 86 505 women, 14% delivered by intrapartum CS, 3% by emergency CS and 2% by elective CS. For intrapartum, emergency and elective CS, the main maternal risk factors were, respectively: previous CS, referral from another facility and suspected cephalopelvic-disproportion (adjusted Odds Ratios from 2.8 to 8.9); vaginal bleeding near full term, hypertensive disorders, previous CS and premature rupture of membranes (adjusted ORs from 3.9 to 10.2); previous CS (adjusted OR=19.2 [17.2-21.6]). Access to adult and neonatal intensive care, a 24-h/day anaesthetist and number of annual deliveries per hospital were independent factors that affected CS rates according to degree of urgency. The presence of obstetricians and/or medical-anaesthetists was associated with an increased risk of elective CS (adjusted ORs [95%CI] = 4.8 [2.6-8.8] to 9.4 [5.1-17.1]).

Conclusions: We confirm the significant effect of well-known maternal risk factors affecting the mode of delivery. Available resources at the institutional level and the degree of urgency of CS should be taken into account in analysing CS rates in this context.

Figure 1

Flow chart. A total of 91,028 women delivered in the 46 referral hospitals selected for the QUARITE trial during the first year of the trial (from October 2007 to October 2008). Five hospitals were excluded from the analysis: four did not carry out any caesarean deliveries during the study period and one had data from mid-2008 only. ^$ Spontaneaous abortion was defined as birth weight less than 500 grams.

Figure 2

Proportions of vaginal deliveries (both spontaneous and instrumental), emergency, intrapartum and elective caesarean sections in each study hospital and according to the type of hospital (district hospitals, regional hospitals and hospitals in the capital). The proportions of elective, emergency and intrapartum caesarean sections varied between hospitals, ranging from 0–8.3% (median: 1.3%), 0–12% (1.9%), and 4.5–38.7% (14.4%) of all deliveries, respectively.