Canadian Journal on Scientific and Industrial Research Vol. 3 No.

4, May 2012

179

Non-medical factors affect caesarean section
rates among developing countries


*Maha M., Atout

*Lecturer of Maternity and Newborn nursing, Isra University
E.mail: maha.atout@iu.edu.jo, Tel: 00962799114502




Abstract_ Presently, the Caesarian section (C/S)
has become widely used in developing countries
where it can be a life-saving procedure for mother
or baby. It may carry severe health problem for the
mother and newborn. Cesarean section rate
continues to rise in many countries with routine
access to medical services, yet this increase is not
associated with improvement in perinatal mortality
or morbidity. This raises a range of concerns about
the use of caesarean section for non- medical
indications. The next review addresses factors that
affect the increase in C/S rate in the developing
countries without medical indications.

Key Words: Caesarian section, prenatal mortality,
non- medical indications, developing countries


I. INTRODUCTION

Recently the rate of cesarean section (C/S) has
grown rapidly. Not only in the developing
countries, but also the developed countries have
showed a significant increase [1].

As a surgical procedure, it's the most frequently
performed in the united state. Approximately one
out of four women will have cesarean delivery in
her reproductive years [2]. This increase has raised
the concern about the unnecessary C/S without
medical reasons.

In 2007 the rate of C/S rate in the United State
arrived 29.1%, which considered the highest among
the developed countries. About one third of the C/S
operations were repeated procedures. [3]

Among developing countries, the rate of C/S in
the majority of them was between 5%-15 % as
shown in the next table. Around 4%- 18% of them
were performed on maternal request [1]. Although
the disparities that found between these countries,
especially poor and rich, they had an enormous
increase in the rate of cesarean section in the last
century [4]


Compared with normal vaginal delivery, C/S
delivery may carry severe health problems for both
newborn and mother. For newborn it may lead to
respiratory complication and neurological deficits,
for mother it may increase the long-term morbidity
that may happen postpartum [5]. Furthermore, there
is an elevated risk of unexplained stillbirth in
subsequent pregnancies among women with
previous multiple caesarean section.[6] Caesarean
section may require more healthcare resources,
which consider a real burden on the health care
systems, especially with limited budgets. [7]

On the other hand C/S help reduce maternal and
perinatal mortality when contraindication of normal
vaginal delivery is present, or when the progression
of labor is thought to be unsafe [6], because of the
debate emerged about the risks and benefits for the
C/S operation, World health organization (WHO)
states that it is not justified in any place of the
world to perform C/S operation in a rate greater
than 10%-15%.

II.
IM OF THE REVIEW

The aim of this review is to explore the non-
medical factors associated with caesarean section
rate in the developing countries


Rate of
C/S
Less than 5
%
Between
(5-15) %
More than
15 %
Name of
country
Yemen,
Mauritania,
Sudan,
Algeria
Oman,
Morocco,
Libya,
Tunisia,
Saudi
Arabia,
UAE,
Egypt,
kuwiat,
Jordan,
Syria
Lebanon,
Qatar,
Bahrain
Canadian Journal on Scientific and Industrial Research Vol. 3 No. 4, May 2012

180


III. L
ITERATURE REVIEW

This section addresses non- medical factors
associate rates of C/S in developing countries.
Literature has revealed three major non-medical
factors affected C/S rates:

1. Physician -related factors:
Physicians are generally thought to play the
dominant role in the medical care decisions. Some
patients may leave the health-care related decision
to the physician, because they trust his knowledge
and expertise. There are many non- medical
factors affect physicians' opinions toward the route
of delivery as they mentioned below:

a. L
ack of second opinion consultation
Lack of second opinion consultation was found
to affect physicians' decision toward route of
delivery. As it was found in the qualitative study
conducted to determine factors affect obstetricians'
decision on the route of delivery among 19 boards
certified obstetricians working in four Jordanian
hospitals. The findings of the study showed that
100% of those obstetricians claimed that absence of
second opinion consultation especially in the high-
risk deliveries plays a significant role in the
increase in the C/S rate [8]

b. Fear of professional liability:
Legal claim against obstetricians for negligence
was found to affect C/S rates. Physicians tend to
move toward safer practice with low level of
professional liability. This was supported by the
Jordanian study that was conducted to explore
factors affect physicians' decision on the route of
delivery in high- risk pregnancies. It was found that
the fear of professional liability for the physician
had an impact on delivery decision, especially with
high-risk pregnancies such as assisted birth that
could affect the life and health of the neonate and
mother. [8]
In addition, a study conducted in Ireland to
estimate proportion of obstetricians who would agree
with elective C/S on maternal request. The result
showed that there was a positive relationship between
fear from professional litigation and the tendency
toward C/S operation. [9]

c. Age and clinical experience
Older and more experienced physicians were
found to perform lower C/S rate than younger and
less experienced as it found in a study that was
conducted to assess factors affecting the
obstetrician decision toward the route of delivery in
high- risk pregnancies. [8]
Another study was conducted to determine the
impact of demographical factors such as age,
working environment and personal birth experience
of the physician on the attitude towards elective
C/S without medical indication. Results showed
that younger physicians approved C/S on demand
greater than physicians between 50 and 60 years of
age, which may be due to working experience. [10]

d. Gender of physician:
In the Jordanian study that was conducted to
address physicians' characteristics and their effects on
type of delivery decision [8]. Male physicians were
found to prefer C/S mode of delivery. That gender
difference remains not understood. However, the
researcher explained reason for this difference could
be the deep understanding of the female physician for
the female body system.

However, opposite results were found related to
the physician gender and C/S route of delivery. As it
was found in the follow-up study that showed that
(31) % of female obstetricians would choose cesarean
section operation for themselves without medical
reasons [8]. This study was the background for
another study in 2002 where female obstetricians
were asked about their personal choice for mode of
birth. The findings showed that (15.5) % would
choose an elective caesarean [11].

In conclusion, there is a debate related to the
physician's gender effects on the route of delivery,
therefore more studies should be conducted to explore
how gender differences among physicians affect their
decision of delivery type.

2. Women- related factors:
The preference of women to perform C/S
instead of normal vaginal delivery is one of the
most important factors for the increasing rate of
C/S in the developing counties. Literatures have
explored many factors that affect women's
decision toward route of delivery:

a. Lack of information
A qualitative study that was conducted in
Lebanon in 2007 to investigate the environmental
factors that affect the C/S option among different
stockholders. Results showed that lack of
information about the post-partum period
following the C/S operations affect women
decisions of the route of delivery. In the previous
study the result emerged that the painless idea of
C/S compared with pain received during normal
vaginal delivery affect their decision when they
planned to get birth. [6]

a. Fear of childbirth
It is common for women to feel fearful about
childbirth. Childbirth is known to be
Canadian Journal on Scientific and Industrial Research Vol. 3 No. 4, May 2012

181

unpredictable and painful and accomplished with
small risks of morbidity or even death for mother
and fetus. Fear from childbirth may vary among
women. Some women would overcome and cope
well with her fear, while others may have an
extreme fear or anxiety; this may leads her to
cope with her fear by request for cesarean section
without medical indications. [12]

A qualitative study was conducted to describe
Australian womens request for caesarean section
in the absence of medical indicators. Results
showed that the most important reason for
requesting C/S operations was fear of giving birth
vaginally especially in the first pregnancy. The
analysis suggested that fear of giving birth
vaginally for some women was reinforced by
difficult birth experience that was shown by the
mother of pregnant woman [13]
b. Women age

Trends in cesarean section rate with maternal
age have been of interest in the last 10 years.. As it
was shown in the retrospective study which
conducted to assess the effect of maternal age on
C/S rate among 11.815 patient. Results revealed an
increase in C/S rate with increasing maternal age.
[12]
Another study found that women age at first
pregnancy is another factor that could affect
women choice for type of delivery. The researcher
found that older age women at first pregnancy
prefer C/S delivery more than younger. This was
discussed that the underlying cause for C/S choice
for older women at first time pregnancy was their
believes that it's the safer way to get a child. [13]

c. Level of education
Level of education was found to affect C/S rate.
This was supported by the Chinese study
that was conducted to explore the effect of
educational levels and the employment of the
mother on the route of delivery among Chinese
women. Results showed that there was an
association between high educational level and the
employment of the mother on the increasing C/S
rate. The researcher explained that better- educated
women were more likely to have babies at
relatively late age. [14]

d. Previous infertility
Previous infertility was found to increase C/S
rates as some people think that C/S is the safer
way to get child. In a study that was conducted in
Nigeria in 2006 to assess women reasons for
requesting C/S operations among 27 women who
requested C/S without medical indications. Oral
questionnaire was administered previous delivery
and after 6 week postnatal. Results showed that
the major reasons among Nigerian women to
request C/S operations were previous infertility
(40.7) %. The underlying aim of this choice was
the desire of having a live birth to beat the
problem of infertility. They believed that C/S
offered them the best chance of fulfilling their
desire [15]
e. Community factors: (social interaction,
urbanization level)

Social interaction
Community factors have an impact on the
rising in the number of C/S in developing
countries. Depends on a study that was conducted
to analyse the community factors that affect the
rate of C/S among six developing countries.
Results showed that women, who have a high
social interaction, were associated with lower
incidence of C/S choice. because women who
share information with others social sources
would be more likely to be informed about the
potential harms that may result from C/S, such as
hospitalization, recovery time, pain from
operation, and breastfeeding problems [16]

Level of urbanization
In the developing countries the trend for
urbanization is another factor that affects the route
of delivery, depends on the results of a study that
was conducted to examine the association
between urbanization and the risk for C/S among
Egyptian women. It was found that the increase
the urbanization level was associated with the
increase of C/S rate. One possible explanation for
this association was that the higher level of
urbanization would correspond with lower
fertility rate [1]

The explanation of that was cleared in another
study which conducted in Taiwan to explore
possible explanations for the higher C/S rate
among urban areas. lower fertility rate in the
urban areas in comparison with those in rural
areas, raised the focus for people live in urban
places to focus more attention on the safety of the
baby, therefore choosing the safer way to get
child (in their opinion C/S safer than normal
vaginal delivery). As a result increase C/S rate [9]

In conclusion, C/S rate was shown to increase
in urban areas more than rural places. Because the
lower fertility rates that were seen in the urban
areas.

3. Management factors:

Management factors have been shown to play a
significant role in explaining C/S rates for non
clinical indications. It has been classified into four
categories: hospital characteristics, lack of midwife
Canadian Journal on Scientific and Industrial Research Vol. 3 No. 4, May 2012

182

type of health insurance coverage, and the diversity
of health care centers among some countries.

a. Hospital characteristics
Hospital characteristics were appeared to
influence C/S rate as it was found in the Jordanian
study that aimed to study factors affect the
obstetrician decision on the route of delivery
among two groups of military hospitals. It was
found that the presence of full-time obstetric
anesthesiology, teaching institution, large delivery
unit capacity, urban location of the hospital, and the
presence of qualified medical staff and neonatal
intensive care unit, all of these hospital
characteristics factors may decrease the rate of
caesarean section operations [2]

b. Lack of midwifes in the labor units
There is a relationship between the presence of
an enough number of midwifes, and the mode of
delivery. Depends on the previous Jordanian study,
the presence of qualified midwifes would decrease
the rate of C/S. [2] This study was supported by
another study that concluded that the presence of
qualified midwifes in the labor settings had an
effects on numbers of C/S operations. For
example, a country like Egypt characterized by lack
of trained midwifes has a high proportion of C/S. In
contrast to Syria and Palestine which had a
significant proportion of qualified midwifes, have
moderate C/S rate. [1]

c. Type of Health insurance coverage
It was found that C/S decisions were affected
by type of health insurance that carried by women
who seek the health institution as it will emerge
from the next studies.

In one study that conducted in 2007 to
differentiate between private and public hospitals in
term of their relation to increase C/S rate among
nulliparous women. It was found that with private
insurance women had more tendencies to decide
C/S delivery rather than those who hadn't private
insurance. [17]

Furthermore, some countries have health
insurance systems that don't cover analgesia related
to normal vaginal delivery, such as epidural
analgesia, in contrast to total financial coverage for
C/S analgesia such as (spinal or epidural included
in C/S).These systems encouraged women to move
toward the cost- effective route of delivery, which
means C/S deliveries.[6]

d. The diversity of health care centers
Maldistribution of health care centers was
found to affect C/S rates as it was found in the
retrospective study that conducted to look for the
socioeconomic differences in C/S rates in 13
developing countries. Results showed that less
than 1% of the population in the poorest countries
such as Sub-Saharan Africa could apply C/S, even
in the life-saving cesarean, which had negative
effects on the pregnant women and fetus health
outcome. This has been explained for this
problem: the health care services might not exist
because of poverty, or it can't be reached because
of the misdistribution of health centers [18]

Data from Latin America suggested that the
surgical services were available to cover a large
number of population, but the distribution of these
services was not optimal that would deprive large
areas from these services. As a result the distance
needed to reach the hospital to perform surgical
procedure would make time and financial barrier.
On the other hand, countries such as
Nicaragua and Bolivia which are considered
highly-incomed, had high proportion of C/S
arrived to 44 %. This improper distribution had a
significant effect on the health on mother and
infants [18]
In conclusion, many studies reported that
maldistribution of health care facilities in some
countries may affect C/S rate among them. Since,
the large distances that could be passed to arrive
the health centers will create a time and financial
barriers. This may prevent pregnant women from
seeking any surgical interventions. Even with life-
saving cesarean section. As a result decrease C/S
rates.

IV. CONCLUSION

Several studies suggested that there were non-
medical indications that may influence the decision
of use caesarean section as a method of delivery.

There are three non medical factors that affect
cesarean section rate; physician related factors,
women related factors, and management related
factors. Physician related factors may include: lack
of second opinion consultation, fear from litigation,
and physician characteristics (age, clinical
experience, and gender), Women related factors
may include: lack of information, previous
infertility, fear from childbirth, economical status,
and women characteristics. Management related
factors were: type of health insurance, lack of
midwifes in labor units, diversity of health services,
and hospital characteristics.
Further studies are needed to provide the
literature with an updating statistics that give a new
and accurate figure to the decision maker, also
more financial support should be offered for the
researcher to support their studies on this important
health topic, toward natural delivery, this is the new
international trend to improve health of the mother
Canadian Journal on Scientific and Industrial Research Vol. 3 No. 4, May 2012

183

and fetus, and this is the main goal that we seek to
arrive in the maternal and newborn health nursing.



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VI. BIOGRAPHIES

Maha Mohd Wahpi Atout,
Lecturer at Nursing Faculty/ Isra
University. Birth date and place:
November 15
th
1984, Amman,
Jordan, B.Sc. Nursing science,
Faculty of Nursing, Jordan
University, Amman, 2006. M.S.N: Maternity and
Newborn, Jordan University for Science and
Technology, 2009

RT