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Research Article | Volume 15 Issue 2 (Feb, 2025) | Pages 20 - 23
Indications and Rate of Caesarean Delivery in a Zonal Hospital in Kanpur, Uttar Pradesh: a Retrospective Study
 ,
 ,
1
Asst Professor, Obstetrics & Gynaecology, 7 Air Force Hospital, Kanpur, Uttar Pradesh, India
2
Assoc Professor &HOD, Obstetrics & Gynaecology, Command Hospital Lucknow, Uttar Pradesh, India
3
Assoc Professor, Obstetrics & Gynaecology, 7 Air Force Hospital, Kanpur, Uttar Pradesh, India
Under a Creative Commons license
Open Access
Received
Dec. 29, 2024
Revised
Jan. 5, 2025
Accepted
Jan. 21, 2025
Published
Feb. 3, 2025
Abstract

Background: Caesarean deliveries are one of the most commonly performed surgeries in this world. However, the past decades have witnessed a gradual rise in the caesarean section rate in India as well as worldwide. The objective of this present study is to analyse the rate and indications of caesarean delivery over a five year period in 7 Air Force Hospital, Kanpur, Uttar Pradesh. Methods: This is a retrospective study that analysed the rate and indications of caesarean delivery that took place over five years from 01 Jan 2019 to 31 dec 2023. Data of the patients was obtained from the hospital records and statistical analysis was done. Results:  There was an overall rise in the rate of caesarean delivery from 21.3% in 2019 to 32.2% in 2023. Previous caesarean status was the most common indication. There was an increase in primary caesarean section as well from 10% in 2019 to 24% in 2023. At the same time, there was a reduction in the incidence of neonatal birth asphyxia from 1.28% in 2019 to 0.5% in 2023. Conclusion: Efforts should be made to ensure that every caesarean delivery is medically justified and that every patient who needs a caesarean delivery receives it on time, instead of trying to achieve a specific rate of caesarean delivery. At the same time, patient education, better intrapartum care, improved monitoring of labour and regular audits can help us minimize the rate of caesarean delivery over time.

Keywords
INTRODUCTION

Caesarean deliveries are one of the most commonly performed surgical procedures in the world. It is a surgery to deliver the fetus by giving incision over the abdomen and over the uterus. In recent years, there has been an increasing trend towards caesarean deliveries in most of the countries. As per WHO, the rate has nearly doubled from 12.1% in 2000 to 21.1% in 2015 (1). In India, we have witnessed a gradual increase in the rate of caesarean deliveries as well,from 17.2% during National Family Health Survey-4 (NFHS-4 (2015-16)) to as high as 21.5% during NFHS-5 (2019-21)(2). The reason behind this rise is multifactorial. The most common indication is fetal distress, followed by previous caesarean delivery and antepartum haemorrhage. Maternal request is the most common non-medical indication(3).

 

Caesarean deliveries are lifesaving surgeries for both the mother and the baby when medically indicated. However, in the recent years there has been a growing public concern regarding the increasing rate of caesarean section (3)(4). WHO in the past had suggestedthat if the rate of caesarean section exceeds10-15%, it may not lead to better maternal and neonatal outcomes. This statement has been criticized for several reasons and so WHO released a statement in 2015 mentioning that every effort should be made to provide caesarean sections to a woman in need rather than to achieve a specific rate (1)(5).

 

The present study was conducted in a zonal hospital in Kanpur, Uttar Pradesh. The objective of this study was to analyse the rate and indications of caesarean delivery performed over a period of five years.

METHODS

This is a retrospective study of all deliveries that had taken place from 01 Jan 2019 to 31 Dec 2023 in 7 Air Force Hospital, Kanpur, Uttar Pradesh. This hospital is a zonal hospital that caters to the need of serving soldiers, ex-servicemen and their dependents. This hospital cares for over 1000 deliveries every year.

 

The objective of this study is to analyse the trend and indication of caesarean deliveries in our institute. The data was obtained from the hospital records after necessary permission was obtained from the institutional ethical committee.

RESULTS

Year

Total delivery

 

Caesarean delivery

CS rate

2019

1094

233

21.3%

2020

1027

307

29.9%

2021

896

238

26.6%

2022

1069

282

26.4%

2023

1176

379

32.2%

Table 1: Year wise deliveries, LSCS and LSCS rates

 

Year

Primary

LSCS

Primary LSCS rate

2019

96

10%

2020

159

18%

2021

140

17.5%

2022

168

17.5%

2023

251

24%

Table 2: Year wise Primary LSCS and primary LSCS rate

 

 

2019

2020

2021

2022

2023

 

Previous LSCS status

 

137

(58.8%)

148

(48.2%)

98

(41.17%)

114

(40.43%)

128

(33.77%)

Abnormal lie/presentation (breech/transverse lie)

 

31

(13.3%)

34

(11.07%)

36

(15.13%)

22

(7.8%)

31

(8.18%)

Fetal distress

24

(10.3%)

45

(14.66%)

33

(13.87%)

50

(17.73%)

65

(17.15%)

Non-Progress of Labour

 

06

(2.58%)

29

(9.45%)

25

(10.5%)

28

(9.93%)

72

(19%)

Failed Induction

07

(3%)

21

(6.84%)

18

(7.56%)

22

(7.8%)

40

(10.55%)

Second stage arrest

08

(3.43%)

10

(3.28%)

11

(4.62%)

20

(7.09%)

20

(5.28%)

Antepartum Hemorrhage (Placenta previa/ Abruptio placenta)

10

(4.29%)

8

(2.6%)

6

(2.52%)

10

(3.55%)

7

(1.85%)

Multifetal Gestation

10

(4.29%)

 

12

(3.91%)

11

(4.62%)

9

(3.19%)

7

(1.58%)

Total

233

307

238

282

379

Table 3: Year wise indications of LSCS, frequency and rate

 

 

Frequency of birth asphyxia

 

Rate

2019

14

1.28%

2020

10

0.97%

2021

10

1.11%

2022

9

0.84%

2023

6

0.5%

Table 4: Year wise frequency and rate of birth asphyxia

 

The analysis shows an overall rising trend in the incidence of cesarean deliveries in our hospital from 21.3% in 2019 to 32.2% in 2023 (Table 1). There rate of primary caesarean sections has more than doubled from 10% in 2019 to 24% in 2023 (Table 2).

 

In all these five years the commonest indication for caesarean deliveries has been previous caesarean status. Abnormal lie/presentation was the second most common indication in 2019 and 2021 respectively, whereas fetal distress was the second most common indication in 2020 and 2022. Caesarean delivery due to non-progress of labour was second most frequent indication in 2023 after previous caesarean status (Table 3).

 

Along with rising caesarean rate, there was also a more than double reduction in the frequency of birth asphyxia from 1.28% in 2019 to 0.5% in 2023 (Table 4).

DISCUSSION

The increasing frequency of caesarean deliveries has been a growing public health concern. In South Asia the frequency has increased from 7.2% to 18.1% between the year 2000 to 2015 (1). The frequency has also been increasing in India from 17.2 % (2015-16) to 21.2% (2019-21) as per the data from National Family Health Survey (NHFS) (2). Several studies have tried to explain the causes behind this. Studies have suggested that increase in maternal age at childbirth, rising maternal obesity and increase in multifetal gestation in the recent times have been important contributing factors(6)(7)(8). Changes in obstetric management for breech presentation, multifetal gestation, suspected growth retardation and reduction in the willingness of instrumental delivery are some of the other important factors (6) (9). Caesarean delivery on maternal request has been found to be the most common non-medical factor. The main reason behind this is fear of labour pain and perineal trauma, as well as convenience and certainty. Cervical laceration, vaginal tear, and the stress of healing and recovery plays in the back of the mind of most individuals. Apart from this, a good “Mahurat” or an auspicious time for childbirth as per religious beliefs plays an important role in the decision making even in the educated and elite class of women in the Indian society(10)(11).

 

Fear of litigation among obstetricians is another important non-medical factor. Obstetrics is one of the leading specialties in terms of litigation risks and cost. The care provider has to ensure a good outcome for both the mother and the fetus, and the prevailing norms in the present scenarios such as a growing intolerance towards complications compels the obstetrician to keep a lower threshold towards caesarean deliveries (12)(13).

 

Our study has shown a rising trend of caesarean section rate in our hospital from 21.3% in 2019 to 32.2 % in 2023. The most common indication in all these five years has been previous caesarean status. Trial of labour in post caesarean patients is usually not practiced in our hospital as a routine. This is mostly because of doubtful scar strength, unavailability of details regarding previous caesarean delivery and unwillingness of the patients for a trial of labour.

 

Fetal distress, abnormal presentation/lie and non-progress of labour have been fairly common indications as well. These indications are also responsible for the increase in the primary caesarean section rates, from 10% in 2019 to 24% in 2023. Efforts are being made to reduce the primary caesarean rate by implementing suitable protocols for labour induction, judicious use of various methods for labour augmentation and the use of partogram/ WHO Labour Care Guide in every cases. It is also worth noting that along with the rising rate of caesarean delivery, the incidence of birth asphyxia has also reduced from 1.28% 2019 to 0.5% in 2023. This is mainly because of better methods of monitoring during labour and early intervention measures that are being practiced in this hospital.

CONCLUSION

A growing rate of caesarean section has been seen as a matter of concern in public health(14)(15). However, instead of aiming to achieve a specific rate, efforts should be made to ensure that every caesarean delivery is medically justified and that every patient who needs a caesarean delivery receives it on time. The WHO statement released in 2015 has also emphasized the same (1)(16).

 

Improving intrapartum care and better monitoring facilities will not only help to identify complications on timebut will alsohelp in deciding whether a patient requires caesarean delivery or not. The WHO Labour Care Guide published in 2020 is a great manual for this purpose(17). It is based on current evidence, and is different from previous partograms regarding labour duration, timingfor clinical intervention and emphasis on respectful maternity care.

 

Regular audits at the institutional level will also help in identifying the cohort of patients where the rate of caesarean deliveries can be reduced through appropriate measures. The use of Robson’s classification is an essential tool in this regard (18)(19). This simple-to-use classification system is easily reproducible and allows to easily identify target groups of patients where interventions can be made to reduce the overall rate of caesarean deliveries.

 

At the same time, patient education regarding labour and how to handle it is of great importance. It will help in allaying the fear and concerns about childbirth and perineal trauma, and therefore, will help in better decision making as per as caesarean delivery on maternal request is concerned. Awareness about vaginal birth after caesarean (VBAC) and its advantages can also help patients make an informed decision, and this may lead to a reduction in the overall rate of cesarean deliveries.

 

Conflict of interest: None

Funding Received: None

REFERENCES
  1. World health Organisation. WHO statement on Caesarean Section rates. Geneva: World Health Organisation; 2015
  2. Tripathy B, Jena A, Pandey AK, Mishra SS, Mishra C. Caesarean Section Delivery in India: A Comparative Assessment of Ge- ographical Variability Using Nationally Representative Survey Factsheet Data. Natl J Community Med 2023;14(4):260- 266. DOI: 10.55489/njcm.140420232650
  3. Dhakal-Rai S, van Teijlingen E, Regmi P, Wood J, Dangal G, Dhakal KB. Factors contributing to rising cesarean section rates in South Asian countries: A systematic review. Asian Journal of Medical Sciences. 2022 Feb 1;13(2):143-74.
  4. Umar, Badar Uddin; Haque, Mainul1,.Growing Concern Over Rising Caesarean Section Rates: Is it a Problem for Low- and Middle-Income Countries Only?. Advances in Human Biology 12(2):p 93-100, May–Aug 2022. | DOI: 10.4103/aihb.aihb_148_2
  5. Verma V, Vishwakarma RK, Nath DC, Khan HT, Prakash R, Abid O. Prevalence and determinants of caesarean section in South and South-East Asian women. PloS one. 2020 Mar 12;15(3):e0229906.
  6. Balla PC, Nallapu SS. A review of caesarean section rates in India: causes for increased prevalence and suggestions for a rational approach. Int J Reprod Contracept Obstet Gynecol. 2022;11(4):1324.
  7. Sungkar A, Basrowi RW. Rising trends and indication of caesarean section in Indonesia. World Nutrition Journal. 2020 Oct 1;4(S2):1-7.
  8. De Vries BS, Morton R, Burton AE, Kumar P, Hyett JA, Phipps H, McGeechan K. Attributable factors for the rising cesarean delivery rate over 3 decades: an observational cohort study. American Journal of Obstetrics & Gynecology MFM. 2022 Mar 1;4(2):100555.
  9. Patel BS, Kedia N, Shah SR, Agrawal SP, Patel VB, Patel AB. Changing trends in cesarean section: from 1950 to 2020. Int J Reprod Contracept Obstet Gynecol. 2020 May 1;9(5):2222-6.
  10. Rai SD, van Teijlingen E, Regmi PR, Wood J, Dangal G, Dhakal KB. Caesarean section for non-medical reasons: A rising public health issue. Journal of Karnali Academy of Health Sciences. 2021 Dec 14;4(2).
  11. Parikh KS, Pandya ST. “Too powerful to Push”: A Rise in “On Demand” Caesarean Section. Journal of Obstetric Anaesthesia and Critical Care. 2021 Jul 1;11(2):56-8.
  12. Elaraby S, Altieri E, Downe S, Erdman J, Mannava S, Moncrieff G, Shamanna BR, Torloni MR, Betran AP. Behavioural factors associated with fear of litigation as a driver for the increased use of caesarean sections: a scoping review. BMJ open. 2023 Apr 1;13(4):e070454.
  13. Fineschi V, Arcangeli M, Di Fazio N, Del Fante Z, Fineschi B, Santoro P, Frati P, Associazione Consulcesi Health and ONLUS Futura Ricerca. Defensive medicine in the management of cesarean delivery: a survey among Italian Physicians. InHealthcare 2021 Aug 25 (Vol. 9, No. 9, p. 1097). MDPI.
  14. Umar, Badar Uddin; Haque, Mainul1,.Growing Concern Over Rising Caesarean Section Rates: Is it a Problem for Low- and Middle-Income Countries Only?. Advances in Human Biology 12(2):p 93-100, May–Aug 2022. | DOI: 10.4103/aihb.aihb_148_21
  15. Pandey AK, Raushan MR, Gautam D, Neogi SB. Alarming Trends of Cesarean Section—Time to Rethink: Evidence From a Large-Scale Cross-sectional Sample Survey in India. Journal of Medical Internet Research. 2023 Feb 13;25:e41892.
  16. Betrán AP, Zhang J, Torloni MR, Gülmezoglu AM. Determination of a single, universal threshold for caesarean section rate is not the way forward. Evid Based Med. 2016 Dec;21(6):237. doi: 10.1136/ebmed-2016-110393
  17. Hofmeyr GJ, Bernitz S, Bonet M, Bucagu M, Dao B, Downe S, Galadanci H, Homer CS, Hundley V, Lavender T, Levy B. WHO next‐generation partograph: revolutionary steps towards individualised labour care. Bjog. 2021 Sep;128(10):1658.
  18. Tamang T, Dema J, Pelden S, Choden P. Usefulness of Robson classification system to analyze caesarean section deliveries: a hospital based study. Bhutan Health Journal. 2020 May 15;6(1):38-44.
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