Magnitude of maternal complications and associated obstetric factors among women who gave birth by cesarean section at Arba-Minich General Hospital, Southern Ethiopia: Retrospective cohort

Cesarean section is the most common major surgical procedure in obstetrics and gynecology in the world. Though advance in cesarean section technique, it still poses higher maternal morbidity and mortality than vaginal delivery. This study aimed to determine the magnitude of maternal complications (Including the presence of one of the intera-operative surgical complication or postoperative maternal complication; postoperative complication-is defined as the existence of one of the following; febrile morbidity, extended antibiotics treatment, extended hospital stay, wound infection (SSI), deep venous thrombosis (DVT), pneumonia, admission to Intensive Care Unit (ICU), drop in hemoglobin/hematocrit (HCT/HGB), blood transfusion, postpartum hemorrhage (PPH) maternal death in the Hospital) and associated obstetric factors among women who delivered by cesarean section at Arba-Minch General Hospital, Sothern Ethiopia Hospital based retrospective cohort study was conducted among women who delivered by cesarean section from July 8, 2013 to August 6, 2014 at Arba-Minch General Hospital. Demographic data, obstetric factors and occurrence of intra-operative and postoperative maternal complication during their hospital stay were collected using a pre-tested data collection format. SPSS version 20.0 was used for data analysis. A total of 416 mothers’ charts were reviewed. The mean (±SD) age of the mothers was 25.72 (±5.175 years). Emergency cesarean delivery accounted for 87% of all cesarean deliveries. Fetal distress, Cephalo Pelevic Disproportion (CPD), and obstructed labor accounted half of the indications for cesarean sections. Overall maternal complication rate was 38.2%. Living in rural setting (AOR, 1.4,95%CI:1.0,2.3), maternal age ≥ 30 years, (AOR=2.0,95%CI:1.1,3.8 ), presence of obstetric complications, (AOR=2.6,95%CI:1.4,4.7), operation done in second stage of labor, (AOR=2.5,95%CI:1.3,4.6), labor≥25 h (AOR=1.4,95%CI:1.0,2.4) and general anesthesia (AOR=2.456,95%CI:1.382,4.356) were found to have significant association with maternal complication. Maternal complication was found to be high. Timely management of labor before a woman develops obstetrics complication and use of appropriate anesthesia will reduce the occurrence of complications.


INTRODUCTION
Pregnancy and parturition are events of considerable importance in the life cycle of women. Pregnant women may deliver their children via normal spontaneous vaginal delivery or through cesarean section. Parturition or giving birth is physiological; however, it poses a significant risk to the life and well-being of both mother and child. Of all deliveries, approximately 10% are considered as highrisk, some of which require cesarean section (Abebe et al., 2016).
Cesarean section (CS) is the most common surgical procedure performed on women worldwide. It could be performed as an elective procedure when there is a predictable risk to the mother or fetus during labor or in the presence of an identifiable indication for the procedure.
The procedure is however undertaken as an emergency when a complication of pregnancy or labor warrants quick intervention to deliver the fetus (Jaiyesimi and Ojo, 2003).
Cesarean section significantly reduces maternal and prenatal mortality (Osonwa et al., 2016). The World Health Organization considers Cesarean section rates of 5 to 15% to be the optimal range for targeted provision of these life-saving interventions to mothers and infants (Luz, 2010); lower rates suggest unmet need, while higher rates suggest improper selection (Betran et al., 2007;Ronsmans et al., 2006).
The majority of cesarean deliveries are performed for condition that might pose a threat to both the mother and the fetus if vaginal delivery occurred (Abdissa et al., 2013). Cesarean deliveries are potentially morbid procedures with overall infectious morbidity rates as high as 25% (Padmaleela et al., 2013).
In addition to the increased risk for infections with cesarean section, women are exposed to complications such as excessive blood loss and damage to pelvic organs (Phillips and Brankman, 1990;Atombosoba et al., 2015).
There is an increased risk of uterine rupture, placenta accreta, and placenta previa associated with a previous cesarean section (Starr, 2003). Post-operative complications include endomyometritis, wound infection, fascial dehiscence, urinary tract infections, bowel dysfunction, thromboembolic complications, and pelvic thrombophlebitis (Maimoona et al., 2014). Now a day's caesarean section is safer than it has never been. But, in Africa it is still performed in harmful conditions for saving the mother and fetus (Abubakar et al., 2015, Fesseha et al., 2011.
Although the magnitude of maternal complication following C/S in Ethiopia is high, there are no baseline information regarding maternal complication and associated factors in the study area. Therefore, this study will help in filling the gap of information on magnitude of maternal complication of cesarean delivery and associated obstetric factors contributing to poor maternal outcomes. It can also be used as baseline information for future research.

Study setting
The study was conducted in Arba-Minch General Hospital. The average number of deliveries conducted in this hospital is estimated to be 1800 to 2000 women per year and the average number of cesarean deliveries is estimated to be 450 to 550 women per year

Study design and period
Hospital register based retrospective cohort study design was used. Document of mothers who underwent cesarean section from July 8, 2013 to August 6, 2014 in Arba-Minch General hospital were reviewed. It is a general cohort. In which all women who underwent cesarean deliveries during the study period have had multiple exposure in the study setting during the study period were considered as exposure variables where as developing maternal complication as outcome variables.
In this the study alternate hypothesis may be stated as multiple factors will have relation with maternal complication for those women who underwent casern section where as the null hypothesis states that there is no any relation of the multiple factors for women underwent casern section so as to develop maternal complication.

Population
Women who delivered by cesarean section in Arba-Minch General Hospital from July 8, 2013 to August 6, 2014 were study population. Records of women with ectopic pregnancy (abdominal pregnancy), whose cesarean section was done in other hospital and referred to Arba-Minch General Hospital due to complications and those with incomplete chart records were excluded.

Sampling procedure
All records of caesarean deliveries done at Arba-Minch General Hospital during the study period were traced using delivery room, operation room and postnatal ward log books. The list of all women who gave birth by caesarean section was prepared and selected based on inclusion criteria.

Data collection, processing and analysis
Checklist adopted from emergency cesarean delivery outcome tracing tools and from WHO research format tool which uses proxy events (antibiotics treatment, prolonged hospital stay, prolonged catheterization) in order to identify maternal complication and associated obstetric factors was used for data collection.
Study participants were identified from delivery and postnatal log books. Using a checklist, socio-demographic data, obstetric profiles which are associated with maternal complication and indicators of intra-operative and post-operative maternal complications were retrieved from patient record and operation log book.
Data were coded, entered, cleaned and analyzed using SPSS version 20.0. Descriptive analysis was carried out to explore the socio-demographic characteristics and magnitude of maternal complication following cesarean section. Bivariate and multivariate logistic regression analysis was carried out to examine the relationship between the outcome variable and the selected obstetric factors. Factors for which there was association in the bivariate analysis at P<0.25 were selected for subsequent multivariate analysis using multiple logistic regression.

Quality control measures
To insure quality of data pre-test was done on 10% of the study population and necessary adjustment was incorporated to the questionnaire. In addition, the collected data were checked for completeness, accuracy, and consistency by the supervisor before accepting from the data collectors.

Operational definition
1. Maternal complication: Includes the presence of one of the intera-operative surgical complication or postoperative maternal complication. 2. Postoperative complication-is defined as the existence of one of the following febrile morbidity, extended antibiotics treatment, extended hospital stay, wound infection (SSI), DVT, pneumonia, admission to ICU, drop in HCT/HGB, blood transfusion, PPH maternal death in the Hospital. 3. Severe maternal complication includes one of the following hemorrhage, blood transfusion, hysterectomy, thromboembolism, and intensive care unit admission, postpartum lengths of stay, postpartum antibiotics treatment, adjacent internal organ injury, prolonged catheterization, febrile maternal morbidity and death in hospital. 4. Obstetric complications: Presence of one of the following Antepartum heamorrhage (APH), PROM/chorioamnionities, preeclampsia or eclampsia, obstructed labor, malpresentation, suspected uterine rupture, previous cesarean delivery or gynecology operations. 5. Postpartum hemorrhage: Is defined as estimated blood loss of >= 1000 ml, fall in Hct >10%, post-operative Hct <25%.

Ethical considerations
The study protocol was approved and ethically cleared by the Institutional Review Board of the college of medicine and health science of Hawassa University. Official letter of co-operation was written by school of medicine to the Arba-Minch General Hospital. Information on the studies was given to the hospital officials and team leaders of the respective department about the purposes and procedures. In order to protect the confidentiality of the information, name or ID was not included in written questionnaires.

RESULTS
During the study period from July 8, 2013 to August 6, 2014 a total of 1980 deliveries were attended in Arba-Minch general Hospital, out of which 488 women delivered by cesarean section. The Hospital cesarean section rate was 24.65%. Seventy two patients were excluded from the study because their medical records were either unavailable or incomplete.

Socio-demographic characteristics of the mothers
A total of 416 questionnaires were used for analysis after questionnaires were checked for completeness. Two hundred fifty (66.1%) of the mothers were rural dwellers and 166 (39.9%) of them were urban dwellers.
The mean age of the mother's was 25.72 years with standard division of ±5.175 years. Most of the mothers (51.4%) were in the age group of 25 to 34 years (Table  1).

Maternal obstetric data and medical illness
Written referral papers were used to refer 211(50.7%) of the mothers from other health institutes. Three hundred and thirteen (75.2%) had one or more ANC follow up in the same or other health institution. Majority of the women were nulliparous which accounted for 189(45.4%) followed by 92(22.1%) para-II mothers and the least were 28(6.7%) para-IV and 63(15.1%) grandmultipara women. Operation at gestational age of 37 to 42 weeks or at term were done for 369 (88.9%) of the women. Only 8.7 and 2.6% of mothers were operated at gestational age of <37 weeks and >42 weeks respectively. Of the total mothers who delivered by cesarean section 49 (11.8%) have at least one medical illness during their pregnancy. The leading medical disease were HIV/AIDS among 11(22.44%), diabetes mellitus among 10(20.4%), malaria and Acut Febril illness (AFI) among 25(51.04%) and tuberculosis among 3(6.1%) of the mothers (Table 2). Regarding obstetric complication, 312 (75%) of the mother had one or more obstetric complications during their pregnancy period and 104 (25%) had no obstetric complication (Table 3).

Labor status of mothers
Three hundred twenty three (77.6%) of the women were operated after labor started and 153(46.1) of the women were in labor for >12 h before operation. Membrane was ruptured in 287(69%) of mothers before operation. One hundred and eighty (58.8%) of the women have meconium stained amniotic fluid. One hundred and thirty nine (39.94%) of the women were operated at second stage of labor after fully dilatation of the cervix. Two hundred and forty two (58.2%) of the women were operated at high station of the presenting part (Table 4).

Indications for cesarean section and types of cesarean section
The leading indication for cesarean section was fetal  distress 86(20.4%), followed by CPD 67(16.1%), obstructed labor 62(14.9%) and the least was cord prolaps 6(1.4%). Emergency cesarean section was done for most (87%) of the women after labor started or maternal obstetric complications occurred (Table 5).

Post-operative maternal complication
The overall post-operative maternal complication was 98(23.6%) and 318(76.4%) of the mothers had no postoperative complications. Two of the mothers died either during or immediately after the operation. The major post-operative complications were surgical wound infection among 50 (12%), febrile morbidity among 19(4.6%), PPH among 9(2.2%), DVT among 2(0.5%) and UTI in 1(0.2%) of the mothers. The average duration of catheterization was 1.75 days and the average duration of therapeutic intravenous antibiotics was 1.89 days. The average duration of hospital stay after the operation was 7.73 days with ±SD of 2.83 days (Table 8).

Overall maternal complication
One hundred and fifty nine of the mothers had at least one of the intra-operative or post-operative maternal complications. This makes the overall rate of complication among mothers who delivered by Caesarean section in Arba Minch General Hospital 38.2% (Figure 1).

Neonatal outcomes following cesarean section
A total of 402 (90.3%) of neonates were born alive. Only 60 (14.9%) of the neonates had poor first minute APGAR score. For 153 (38.06%) of the neonates resuscitation was done soon after delivery. Seventy six (18.9%) of the neonate were transfer to pediatric unit and of these 15 neonates died after born alive (Table 9).    general anesthesia (AOR=2.456,95%CI:1.382,4.356) were found to be significantly association with maternal complications (Table 10).
Based on multivariate logistic regression, cesarean section done for an indication of mal presentation have high maternal complication than other indication with 38.2% 61.8% Yes No  (Table 11).
Regarding indications for c/s in this study, fetal distress (20.4%), CPD (16.1%) and obstructed labor (14.9%) account for half of cesarean sections. These findings are consistent with the national c/s review (Fesseha et al., 2011).
Prophylactic antibiotics were given for 93.3% of the mother before operation. This result is consistent with a 94% result from Ethiopian national c/s review (Fesseha et al., 2011). Nevertheless, 50(12.0%) of women developed post-operative wound infection. The rate of wound infection reported in Jimma Hospital was 27.1% of all post-operative maternal complication (Nebreed et al., 2011) which is higher than our findings. The reason could be the difference in sterility technique and choice of prophylaxis antibiotics among the hospitals.
Blood was transfused for 22(5.3%) of women in the operation table. This result is less than the Tikur anbessa hospital study which is 19% (London, 2008). Overall intra-operative surgical complications were 28.6%. This is higher than a 12 and 11.6% results in other studies (Pallasmaa et al., 2008, Ayano et al., 2015. Among 416 cesarean delivery reviewed, two mothers were died immediately after the operation. This finding is better than the national study finding of 2 deaths out of 267 cesarean deliveries (Fesseha et al., 2011) and 5 deaths out of 318 cesarean deliveries in Tikur Anbessa Hospital (Hussen et al., 2014). Among 98(23.6%) of post-operative maternal complications, the leading were wound infection (12%), febrile morbidity (4.6%) and PPH (2.2%). Study done in Bamako Mali reported an overall post-operative maternal infection among cesarean delivery was 20.1% which is less than our finding (Teguete et al., 2012).
Overall maternal complications of cesarean delivery were found to be 159(38.2%). This finding is higher than the results from the national review (Eyowas et al., 2016). One study done in Jimma Hospital reported an overall cesarean section maternal morbidity of 20%, but they were not included accidental internal organ injury and blood transfusion (Woubishet et al., 2016).
Socio demographic and obstetrics risk factors for maternal complication were found to be living in rural setting, maternal age ≥ 30 years, presence of one or more obstetric complications, operation done in second stage of labor, duration of labor ≥25 h and use of general anesthesia.
Those mothers who came from rural setting have 1.452 times more odds of maternal complication than urban dwellers. This could be mothers who came from rural setting or outside Arba-Minch town after prolonged labor and complicated labor.
Mothers who have obstetrics complication during pregnancy or intrapartum have 2.671 times more odds of maternal complication than those mothers without obstetrics complications. Second stage of labor has 2.511 times more odds of maternal complication than operation without labor. Duration of labor ≥25 h have 1.442 times more odds of maternal complication than duration of labor less than 24 h. Operations done under general anesthesia have 2.456 times more odds of maternal complication than operation done under spinal anesthesia. These factors indicate majority of the cesarean section done after the labor is advanced and complicated. Different study in our country and in other African countries indicates complicated labor and use of general anesthesia increase the risk of accidental internal organs injury and hemorrhage due to atony (Pallasmaa et al., 2008;Ayano et al., 2015, Teguete et al., 2012, Woubishet et al., 2016.
Other risk factors that have association with maternal complications were indications for cesarean sections.
Cesarean section done for an indication of  (Woubishet et al., 2016). The average duration of hospital stay after operation was 7.25 days with ±SD 2.865 this finding is higher than the national review of cesarean section in Ethiopia (Hussen. et al., 2014,). Prolonged maternal Hospital stay indicates, there are high maternal complications in Arba-Minch General Hospital.
Generally the magnitude of maternal complications following cesarean section of Arba-Minch General Hospital is high. Factors that have association with high maternal complications were living in rural setting, age of the mothers greater or equal to 30 years, presence of obstetrics complications, operations done in second stage of labor and prolonged labor greater or equal to 25 hours and use of general anesthesia. Indications for cesarean section like obstructed labor, suspected uterine rupture and mal-presentation were other factors that have association with high maternal complications. High obstetric complications and associated factors like obstructed labor, suspected uterine rupture, prolonged and second stage of labor shows laboring mothers were not managed appropriately. Thus, health professionals who are doing caesarean section on second stage of labor, prolonged labor and operation under general anaesthesia should anticipate intra-operative surgical complications and should be prepare to manage complications like, blood preparation.

Strengths and limitations
This study addresses both the intra-operative and postoperative maternal complication. But, maternal complication related factors like body mass index, estimated blood loss, pre-operative and post-operative hematocrit or hemoglobin were not found in the medical records. If they were included in this study, they may affect the outcome. In addition the study could not compare maternal complication of high risk cesarean delivery with low risk cesarean delivery so that, it needs further study.

CONFLICTS OF INTERESTS
The authors have not declared any conflict of interests.