Worldwide, there is a rising incidence of caesarean section, making it one of the most commonly performed procedures in Obstetrics . In recent times, especially in developing countries, caesarean section is increasingly used for delivery due to safe and efficient blood bank services, improved anaesthesia, availability of potent antibiotics and safer surgical practices in contemporary obstetrics . Caesarean section is a surgical procedure to deliver the fetus(es) through an incision made on the abdomen and the uterus after the age of viability    . Its true origin has been lost to antiquity.
Traditionally, caesarean section was performed when there is an unacceptable risk to the mother or baby if a vaginal delivery was to be allowed. Recently, the indications for caesarean section have assumed a worrying dimension and a new trend of performing caesarean sections for no medical indication other than maternal choice is gaining traction, this could have far reaching short and long term implications for the individual and the society at large  . There continues to be an ongoing debate as to what constitutes an acceptable caesarean section rate. The World Health Organization (WHO) recommended that a most, 10% - 15% of women should be delivered by the abdominal route as there is no additional health benefit with a caesarean section rate of greater than 15% . Previously, it was thought that high caesarean section rate was a problem of developed countries. A recent worldwide survey of caesarean section rates in more than 100 countries by the WHO revealed increasingly unacceptable caesarean section rates in developing countries including sub-Saharan Africa  . Caesarean section is not without its complications as a significant number of women continue to die from complications directly or indirectly attributable to caesarean.
The Federal Teaching Hospital Abakaliki is the largest tertiary health institution in Ebonyi State, Southeast Nigeria receiving referrals from affiliate hospitals but since its establishment, no study of this nature has been undertaken. In this study, evaluated the rate, indications and complications associated with caesarean sections at the Federal Teaching Hospital Abakaliki (FETHA).
This was a retrospective study conducted at the Federal Teaching Hospital Abakaliki (FETHA) from January 2012 to December 2017. FETHA was created on the 23rd December 2011 following the acquisition and merger of the defunct Ebonyi State University Teaching Hospital with the Federal Medical Centre Abakaliki by the Federal Government. It is a referral hospital serving the neighbouring states of Enugu, Abia, Anambra, Cross-River and Imo states.
Case notes of patients who had caesarean section were retrieved from the health information management unit. Sociodemographic variables, type, indications for caesarean section and birth outcome data were extracted. Patients who had antenatal care in our facility were considered “booked” while those who did not receive antenatal care but presented on referral following complications in pregnancy or labour were considered “unbooked”. All the surgeries were performed by at least a registrar in the department. Case notes with incomplete records were excluded.
Data was collected using structured proforma and entered into a secured personal computer. Analysis was performed by means of Epi Info version 7. Results are presented in tables, means and simple percentages.
Ethical clearance was obtained from the research and ethics committee of the Federal Teaching Hospital, Abakaliki.
During the period under review, complete case notes of 3850 of the 3908 women who had caesarean sections were retrieved giving a retrieval rate of 98.5%. A total of 11,215 deliveries were recorded at FETHA, giving a caesarean section rate of 34.8%.
Table 1 shows the sociodemographic distribution of parturient women who had caesarean section during the study period. The mean age of the study subjects was 29.3 ± 5.03 years. Almost half (49.7%) of the patients were in the 20 - 29 age group. Almost two-thirds of the patients were urban dwellers and 73.0% of the study population was booked. Multiparous women made up 36.0% while nulliparous women were 12.6%.
The indications for caesarean section are presented in Table 2. The most common indication for an emergency caesarean section was failure to progress in labour with 20.0% contribution, others were for previous caesarean section 13.5%, antepartum haemorrhage 9.2% and presumed fetal distress in 8.0%. About 0.1% of the caesarean sections were done for previous successful repair of obstetric fistula and higher order multiple pregnancy.
Majority of the babies were delivered at term (77.0%) with an average gestational age of 38 ± 2.6 weeks. About 62.5% of the patients had emergency caesarean section while the rest had elective caesarean section. The mean birth weight was 3.03 ± 0.71 kg, there was macrosomia in 8.1%. There was severe and moderate birth asphyxia in 28.7% of the babies born (Table 3).
Fetal and maternal complications are presented in Table 4. More women had
Table 1. Sociodemographic characteristics.
Table 2. Indications for caesarean section.
Table 3. Pregnancy event and outcome.
Table 4. Fetal and maternal complications.
postpartum anaemia with 38.0%, infectious morbidity 11.0% and maternal death was reported in 2.0%. Severe birth asphyxia was recorded among 12.3% of the babies, 18.6% were low birth weight and perinatal death recorded in 3.2% of babies delivered.
Despite the reported high aversion for caesarean section among Eastern Nigerian women  . our study found a caesarean section rate of 34.8% which is more than twice the recommended limit by the WHO . The rate reported from the present study is a more than 100% increase from 16.4% reported by Onoh et al. at the defunct Ebonyi State University Teaching Hospital (EBSUTH) Abakaliki, one of the hospitals that made up the present FETHA . This high incidence rate reported in our study is not an isolated finding. It is comparable to the 35.5%, 34.6%, 34.7% respectively reported by Adekanle in Osogbo . Akinwutan et al. in Ibadan  and Ezechiet al. in Lagos . The reasons for the high incidence recorded in this study are not unconnected with the sheer size of the institution and the geographical region it serves. It is major referral centre serving the host and neighbouring states. Similarly, FETHA is a tertiary centre with junior doctors in training, some of the indications may be found to be justified if subjected to intense scrutiny.
Failure to progress in labour, mainly due to potential or actual cephalopelvic disproportion was the main indication for caesarean section in a fifth patients, this could be attributed to inadequate pelvic development from malnutrition which is rampant in rural Nigeria and a relatively high incidence of teenage pregnancy which accounted for 2.2% of the women . A little over a quarter of the women were unbooked in FETHA, they were referred from other health centres or traditional birth attendant settings mainly for complications in labour or delivery. This is made worse by the almost non-existent, poorly staffed and poorly equipped primary and secondary health care facilities in rural Nigerian communities . An uncommon indication observed in our study was previous successful obstetric fistula repair. The National Obstetric fistula centre for the Southeast region is located within FETHA. These women are preferably delivered by an elective caesarean section . An emerging indication for caesarean section in our setting is a maternal request for caesarean section with no medical basis. We note that our society is witnessing increasing women education and empowerment and they now have greater decision making capacity regarding issues concerning their health.
In this study, about 6 out of 10 women who had caesarean section were delivered by emergency CS. This is similar to 66.4% reported by Inyang in calabar  but less than higher rates reported of 86.6% reported by Garba  in Kano, 80.8% reported by Adekanle  and 77.9% reported by Akinwuntan . These values were reported from Nigerian tertiary hospitals with similar capacity and clientele with FETHA.
Postoperative anaemia was a relatively common morbidity which was reported in 38.0% of our study subjects. This is due to a combination of several factors including antenatal anaemia from malnutrition, poor compliance with iron therapy given that iron deficiency anaemia is the commonest cause of anaemia in this women and a heavy burden of malaria infestation . Maternal and perinatal deaths reported in this study were among the unbooked patients who had emergency caesarean sections. More often than not, these women were referred in moribund states following mismanaged infected prolonged obstructed labours by quacks and traditional birth attendants. Such is not uncommon in sub-Saharan Africa as evidence from similar studies show   .
In conclusion, the high rate of caesarean section and the complications observed in this study are unacceptable. Government should do more to employ appropriate personnel and equip the secondary health sector to bridge the gap currently existing at this level which is the reason why dangerous unorthodox practices still thrive with its attendant implications. There is equally a yearning need to dispel current misconceptions among the populace that patronising the hospital would lead to a deliberate delivery by caesarean. Healthcare should be subsidized otherwise the issue of cost would continue to serve as a deterrent to hospital attendance.
During the period under review, the hospital used paper patient case notes/records. This made it difficult to retrieve the all patient’s casefiles.
The authors received no funding for this study.
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