Cesarean Section Deliveries in One Health Insurance Hospital in

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					       Cesarean Section Deliveries in One Health Insurance
                     Hospital in Alexandria

         Labib NY*, Mortada MM*, Guirguis WW* *, Abd El Aziz HM*
* Family Health Department ,
* * Department of Health Administration and Behavioral Sciences, High Institute of Public Health,
    Alexandria University.
      Cesarean section (CS) rates have been increasing world wide, raising the question of
the appropriateness of the selection of cases for the procedure. The World Health
Organization (WHO) states that no region in the world is justified in having a cesarean
rate greater than 10 to 15 percent. The aim of the work was to determine the trend of
cesarean section deliveries in Gamal Abdel Naser Hospital which is affiliated to the
Health Insurance Organization (HIO). The study was conducted through a descriptive
retrospective approach. The study sample included the a)recorded deliveries between 1998-
2005 (n=15917) for estimating the trend of cesarean section deliveries, and b) the medical
records of CS deliveries at 2002 in the hospital (n=837) for identifying the indications of CS and
their adequacy as a source of information for evaluation of CS deliveries .The study revealed
that; cesarean section rate was high and increasing during the period from 1998 – 2005.The
highest percent was in the year 2004 (57.9%). The trend of increase was significant (χ for linear
trend = 162.717, p= 0.000).Thursdays accounted for the highest percent of both admissions and
deliveries, while Fridays accounted for the lowest percent . More than one half of deliveries
occurred between 2 pm to before 8 pm. More than three quarters of the study sample (77.9%)
did not have trial labour. Only 12.8% of the total study sample had induction and the outcome
of induction was dystocia in 85%.The main indication of cesarean section was previous CS
(41.2%), fetal distress (17.6%), failed trial and failure to progress (11.4%), cephalo-pelvic
disproportion (10.3%), abnormal presentation (5.6%) and ante-partum hemorrhage (3.2%).
Patient's records lack most of the essential information so it was not possible to verify recorded
indication to justify caesarean section.

Key Word: Cesarean Section, Deliveries, Trial labour, Induction, Indication.
     Every year there are an estimated 200 million pregnancies in the world. Each
one of these faces the chance of an adverse outcome for the mother and for the baby.
While risks cannot be totally eliminated once pregnancy has begun, they can be
reduced through effective, affordable, accessible and acceptable maternity care.(1) The
WHO has estimated that almost 10% - 15% of all women develop complications
serious enough to require rapid and skilled intervention including cesarean section
(SC) if they are to survive without lifelong disabilities.          (2, 3)

     A cesarean delivery is performed for many indications, some indications are for
maternal benefit alone , these include: gestational diabetes, pre-eclampsia, failure to
progress in labor, failed induction and dystocia.(4-7) Some are for fetal benefit alone,
these include: malpresentation, cord prolaps, fetal distress and large sized baby.
Some are for both maternal and fetal benefits, These include; abnormal placentation,
cephalopelvic disproportion, and those situations in which pregnancy was
contraindicated. (4-9)

          No consensus exists about optimal CS birth rates. WHO recommended
guidelines stating that CS birth rates should range between 5 and 15 percent,
adding that rates lower than five percent reflect women's lack of access to
life-saving care and levels more than 15 percent carry no additional benefits to
mother or new-born.       (10)   According to the World Health Report 2005 CS rates are
increasing throughout the world (11) raising the question of the appropriateness of the
selection of cases for the procedure.(12) In spite of being a life-saving intervention in
cases of obstructed labor or other indications, it carries risks and can lead to
morbidity of its own. It also leads to what are often major and at times
catastrophic expenditures for clients. Yet, in some countries the number of women
delivering by CS is increasing beyond all reasons.         (11)   Furthermore, unnecessary
caesarean sections may divert scarce resources in situations where many people
cannot get the CS they need for a life-threatening condition. (11,13) Countries with
some of the lowest perinatal mortality rates in the world have cesarean rates under
10%. (14)

          The trend of increasing the CS rate is based on the improvement of skill and
safety of the operation, broadened and not well defined indications, some
demographic, anthropological, socioeconomic, clinical, and health services factors.
(15,16)    The 2005 Egypt Demographic Health Survey (EDHS) obtained information on
the frequency of cesarean section. It shows that one-fifth of the deliveries in the five
years preceding the survey was CS. (17) In Gamal Abdel Naser Hospital, the largest
Health Insurance Hospital in Alexandria, the CS rate was 47.6 % in 2000. This
exceptionally high rate warrants investigation of its indications and determinants, as
basic knowledge to               plan for reducing unnecessary CS with its risk and
complications. So, the present study was conducted with the aim of revealing the
trend of CS, identifying the reported indications, and investigating adequacy of
medical records as a source of information for monitoring and evaluation of CS
deliveries in Gamal Abed El Naser Health Insurance Hospital in Alexandria.

          The study was conducted through a descriptive retrospective approach. It was
carried out at Gamal Abdel Naser Hospital. This hospital is composed of 1001 beds,
of which 52 are allocated to the Obstetrics & Gynecology Department. All deliveries
recorded in the hospital from 1998 to 2005 constituted                the study sample for
estimating the trend of CS deliveries. They summed up to 15917. All records of CS
deliveries conducted in the year 2002 were reviewed via a compilation sheet for
identifying the indications and determining their adequacy as a source of
information for monitoring and evaluation of CS deliveries. They summed up to 837.

Statistical Analysis
     Statistical analysis was conducted using PC with the software SPSS                                                                             version 13.0.
Mann-whitney test count and percentage was used for comparing two independent
quantitative non-normally distributed variables. Chi Square for linear trend was used to
compare differences throughout the studied years. The level of significance selected was the
0.05 level.

     There is a significant trend of increase in CS deliveries (χ for linear trend =
162.717, p= 0.000). It ranged from 33.7% in the year 1999 to 57.9% in the year 2004
(Figure 1). Primary CS constituted more than 50% of all CS deliveries in all years
from 1998 – 2005. The highest percent of primary CS was in the year 2000 (59.3%).
Regarding the repeat CS, the highest percent was in the year 2005 (47.7%), while the
lowest percent was in the year 2000 (40.7%, Figure 2).

     During the year 2002 the highest percent of CS (31.7%) was at the age 30 to < 35
years and the mean age was 32.47 ± 5.33 years. Nullipara and primipara constituted
more than one third of deliveries (37.5% and 36.0%). Only 15.3% had experienced
one abortion. Women with history of two or more still births constituted minimal
percent (0.6%). This fifths of the sample (40.0%) had no previous live births. More
than one third (36.1%) had only one live birth. More than half of the sample (56.2%,
58.8%) had no history of previous abnormal deliveries or CS, while about one third
of them had history of one previous CS (30.0%, Table 1).


                     60                                                                                                 57.9

                                    48.0                                      49.3
                     50                                         47.6

          P e rc e n t





                             1998          1999          2000          2001          2002          2003          2004          2005          2006

Figure (1): Cesarean Section Rate in Gamal Abdel Naser Hospital During the Period
                                                 Prim ary CS    Repeat CS


           45.7    43.3   40.7    41.6    41.2
     80                                             43.6       45.2    47.7


                                 58.4     58.8
           54.3   56.7
                                                    56.4       54.8

          1998    1999    2000   2001    2002      2003        2004   2005
Figure (2): Distribution of CS Deliveries at Gamal Abdel Naser Hospital During the
            Period from 1998-2005 According to the Frequency of Section
Table (1): Distribution of CS Deliveries at Gamal Abdel Naser Hospital During the
           Year 2002 by Age and Some Reproductive Characteristics
                         Variables                                            %
Age in years                                               No.                 %
  Below 20 years                                             2                 0.2
  20 -                                                      54                 6.5
  25-                                                      208                24.8
  30-                                                      265                31.7
  35-                                                      224                26.8
  40 or more                                                84                10.0
Mean ± SD =                                            32.47 ± 5.33
  Nullipara                                                 314               37.5
  Primipara                                                 301               36.0
  Para 2, para 3                                            202               24.1
  Para 4 or more                                             20                2.4
Previous abortions
  No previous abortions                                     623               74.4
  One                                                       128               15.4
  Two                                                        48                5.7
  Three or more                                              38                4.5
Previous still births
  No previous still birth                                   792               94.6
  One                                                        40                4.8
  Two or three                                                5                0.6
Number of live births
  No previous live births                                   335               40.0
  One                                                       302               36.1
  Two                                                       137               16.4
  Three or more                                              63                7.5
Previous abnormal deliveries#
  No previous abnormal deliveries                           470               56.2
  C.S.                                                      345               41.2
  Ventose                                                    91               10.9
  Forceps                                                    23                2.7
  Bilateral cervical tear                                     3                0.4
  Previous CS
  0                                                         492               58.8
  1                                                         252               30.1
  2                                                          75                9.0
  3                                                          17                2.0
  4                                                           1                0.1

    More than one answer allowed

        Pelvic examination was not done for 22.6% of the sample. In about one third of
the sample, the cervix was closed (33.0 %). The interval between admission and
delivery ranged from 2 - <4 hours in about one third of the sample (32.0%).

Table (2): Distribution of CS Deliveries at Gamal Abdel Naser Hospital During the
           year 2002 by Day of Admission, Day and hour of Delivery.
                     Variable                                                 %
Day of admission
 Saturday                                             129                  15.4
 Sunday                                               121                  14.5
 Monday                                               118                  14.1
 Tuesday                                              125                  14.8
 Wednesday                                            111                  13.3
 Thursday                                            163                      19.5
 Friday                                               70                       8.4
Day of delivery
 Saturday                                            119                      14.2
 Sunday                                              116                      13.9
 Monday                                              116                      13.9
 Tuesday                                             124                      14.8
 Wednesday                                           108                      12.8
 Thursday                                            174                      20.8
 Friday                                               80                       9.6
Hour of delivery
 8 am to before 2 pm                                  82                       9.8
 2 pm to before 8 pm                                 447                      53.4
 8 pm to before 8 am                                 308                      36.8

     Thursdays accounted for the highest percent of both admissions and deliveries
(19.5% and 20.8%, respectively). On the other hand, Fridays accounted for the lowest
percent of both admissions and deliveries (8.4% and 9.6% respectively). More than
one half of deliveries occurred between 2 pm to before 8 pm (53.4%), while about one
third of deliveries occurred between 8 pm to before 8 am (36.8 %, Table 2).

Table (3): Distribution of CS Deliveries at Gamal Abdel Naser Hospital During the
           Year 2002 by Prior Trial Labor and their Main Reported Indication.

                                 Variables                         No.               %
Trial labour
CS without trial labour (Elective)                                 652               77.9
CS after trial labour                                              185               22.1
Main indication
Previous CS                                                        345           41.2
    Previous one CS                                                252           73.0
          With tender scar                                         211           61.2
          With no tender scar                                       41           11.9
           - Other indication                                       32            9.3
           - No other indication                                    9             2.6
     More than one CS                                               93           27.0
Foetal distress                                                    147           17.6
Failed trial / Failure to progress                                  95           11.4
Cephalo-pelvic disproportion                                        86           10.3
Abnormal presentation                                               47            5.6
Antipartum Haemorrhage                                              27            3.2
Primary and secondary infertility                                   21            2.5
Decreased liquor / Premature rupture of membranes                   19            2.3
Eclampsia                                                           12            1.4
Twins                                                               9             1.0
Others                                                              29            3.0
                                     Total                         837           100.0
     More than three quarters of the study sample (77.9%) did not have trial labor,
i.e., elective CS. Cesarean section after spontaneous labor constituted 9.3%, while CS
after induced labor constituted 7.3%. Regarding the main indication of cesarean
section, previous cesarean section constituted more than one third of the cases
(41.2%). Out of them nearly three quarters (73%) were previous one CS.                 Fetal
distress, failed trial and failure to progress and cephalo-pelvic disproportion
constituted the main indications for 17.6%, 11.4% and 10.3% of the sample
respectively,   while   abnormal   presentation   and   ante-partum   hemorrhage
represented 5.6% and 3.2% respectively (Table 3).
Table (4): Association Between Induction of Delivery and the Interval Between
           Admission and CS Delivery at Gamal Abdel Naser Hospital During the
           Year 2002.

    Interval between                                Induction                                      Total
     admission and                       No                            Yes
        delivery                  No.            %              No.               %         No.            %
  < 2 hours                       176           96.7             6             3.3          182        100.0
  2-                              255           95.1            13             4.9          268        100.0
  4-                              142           87.7            20             12.3         162        100.0
  6-                              61            77.2            18             22.8          79        100.0
  12 -                            50            61.7            31             38.3          81        100.0
  24 hours or more                46            70.8            19             29.2          65        100.0
          Mean ± SD                 9.617 ± 30.53                14.04 ± 14.02               10.18 ± 28.98
           (Median)                     (3.43)                      (10.22)                      (3.72)
  Total                           730           87.2            107            12.8         837        100.0

           Test of significance               Mann-Whitney U= 8.78                     p= 0.000

Table (5): Distribution of CS Deliveries After Induction of Labour at Gamal Abdel
           Naser Hospital During the Year 2002 by the Outcome of Induction.

              Outcome of induction                                           No.            %
              Dystocia                                                       91            85.1
              Non engaged head / Cephalo-pelvic disproportion                 8             7.5
              Foetal distress                                                 7             6.5
              Ante-partum haemorrhage                                         1             0.9
              Total                                                          107          100.0

       Only 12.8% of the total study sample had induction. There is significant increase
in the percent of cases those underwent induction as the interval between admission
and delivery increased. The outcome of induction were dystocia in 85%, non
engaged head and cephalopelvic-disproportion in 7.5%, fetal distress and ante-
partum hemorrhage in 6.5%, and 0.9% respectively (Tables 4, 5).

       Regarding data denoting adequacy of medical records as a monitor to justify CS
rate, table 6 shows that partogram, regular fetal heart sound follow up (recorded
every 30 minutes), cardiotocography and time of starting induction were not recorded
for the entire study sample (0.0%)

Table (6): Distribution of CS Deliveries at Gamal Abdel Naser Hospital During the
           Year 2002 According to the Denoting Data Regarding Adequacy of Medical
           Records as a Monitor to Justify CS Rate.

                                                          Recorded                 Not recorded        Total
                                                         No.           %           No.      %       No.     %
Partogram                                                 0           0.0          837     100.0    837    100.0
Foetal monitor                                            1           0.1          836     99.9     837    100.0
Foetal heart sound once or twice (FHS)                   754          90.1          83      9.9     837    100.0
Regular foetal heart sound follow up recorded             0            0.0         837     100.0    837    100.0
every 30 minutes
Induction (n= 107)
 Time of starting                                    0/107     0.0    107/107   100.0     107   100.0
        Syntocinon                                  107/107   100.0    0/107     0.0      107   100.0
        vagiprost                                    5/107     4.7    102/107   95.3      107   100.0
Ultrasound                                            816     97.5      21       2.5      837   100.0
Doppler Ultrasound                                     8       1.0      829     99.0      837   100.0
Cardiotocography (CTG)                                 0       0.0      837     100.0     837   100.0
Non-stress test (Outside hospital)                     2       0.2      835     99.8      837   100.0

     Cesarean section has been one of the most important operations in obstetrics
and gynecology as of its lifesaving value to both mother and fetus.                (18)   The World
Bank review of service delivery models in selected developing countries revealed
that a hospital with comprehensive essential obstetric care should be available and
able to provide CS deliveries and blood transfusions in order to reduce the maternal
mortality rate.   (19)   So, within the specialized hospital or tertiary care model, birth is
treated as a medical problem. This has led to huge amounts of unnecessary and
costly medical interventions.         (20)   Cesarean section remains an important area of
controversy because of increase in the rate of this operation worldwide. Breech
presentation, prematurity, increased use of electronic fetal monitoring, and fear of
litigation has been implicated, and obstetricians have been largely blamed for the
rising trend of CS deliveries. (21)

     The present study revealed that CS rates in Gamal Abed El Naser hospital for
the years 1998 to 2005 were very high and the trend of increase was significant (χ2 for
linear trend = 162.717, p = 0.000), the maximum rate was 57.9% in the year 2004. (Fig.
1) This trend coincides with that of other researches in Egypt.(17, 22) However, these
figures were much higher than those reported by these researches. These high CS
rates in the present study may be attributed to the study being a hospital-based and
not a community-based one. Furthermore, Gamal Abdel Naser hospital serves
working women who are more educated and more exposed to stress. Advancing
maternal age may also explain this increase as the highest percent of CS was in the
age group 30 – 40 years, also low parity as nearly three quarters of the sample were
either nullipara or primipara (73.5%, Table 1). In addition, CS rates vary widely all
over the world, but upward increase in the present study is in accordance with a
vast body of researches. (18, 24 - 29)

     The highest percent of admissions and deliveries in the present study occurred
on Thursday, while the lowest percent of admission and deliveries occurred on
Friday (Table 2) to minimize the work at the week end. This result was in
concordance with the Brazil study.(15,16) Also the highest percent of CS occurred
between 2 pm and 8 pm, while the lowest percent occurred between 8 am to 2 am
(Table 2). This was preferred by the obstetrician to make deliveries in late afternoon
and evening, at the end of office hours–the period with minimal supervision relative
to the morning period. Also, because it allows them “to work a minimum of non-
social hours”. This suggests that non clinical factors play a major role in the decision
to perform a CS.    (17)   This result was in concordance with several studies.    (15, 16, 23- 25)

Financial incentives also resulted in higher cesarean rates, where physicians are paid
twice as much for CS as for a vaginal delivery. Even government provision can be
skewed by the greater financial reimbursement given for these than for normal
vaginal deliveries.(26, 30) These financial incentives might explain high CS rate in the
present study.

       On the other hand, CS rate was low in some developing countries as in Jordan.
A study done in 7 major military hospitals recorded a 3.9% increase in the rate of CS
from 1990 to 2001 (from 7.6-11.5 per hundred deliveries).      (18)   This increase compared
with increase in the rate in the USA and in many European countries is very small.
The explanation of why Jordanian cesarean rate is still low despite the increase
internationally was that the same policy is used in most hospitals in Jordan, which is
trial of labor for fetuses weight > 4000 gm, the use of oxytocin in higher doses and for
longer duration and importantly the decrease in performing the procedure for
fetuses gestational age <30 weeks. This policy is due to the absence of highly
qualified neonatology units, as well as supervision and performance of deliveries by
midwives in more than 85% of deliveries, also, the absence of medico-legal pressure.

       The present study also revealed that primary CS constituted more than 50 % of
all CS deliveries from 1998 to 2005. The high primary CS rate might be due to short
interval between admission and delivery for most cases, not allowing enough time
for induction (table 4). There was no follow up by fetal monitor or partogram (table
6). Cesarean section was conducted while pelvic examination on admission was not
done for 22.6%, the cervix was closed in 33.0% and was one finger in 25.8%. This
means that they were admitted for elective CS or did not take trial of labor.

       Cesarean section deliveries after previous one CS constituted the highest percent
(73.0%) of all repeat CS, also they didn't take chance for vaginal birth after cesarean
(VBAC). This might indicate that operative deliveries were done for cases with
previous one CS on an elective basis without any trial of VBAC and this was in
accordance with many studies. (31, 32) Despite the US healthy people 2010 objective of a
VBAC recommended rate of 37 %,(33 ) cesarean delivery rate reached 27.6% in 2003;
more than one third of these were repeat CS. Also, the rate of VBAC fell from 31% in
1998 to 10.6% in 2003.   (34)   This could be justifying the high cesarean delivery rate all
over the world.

     The present study was based on a retrospective record review. One of the study
objectives was to assess the adequacy of information recorded in the patient's record to
verify the indications recorded by the physician and to judge the justification of the
indication. Results revealed that the patient's record lacked most of the essential
information (table 6); partogram, fetal monitor, regular fetal heart sound follow up
recorded every 30 minutes and cardiotocography. Accordingly, it is not possible to
verify recorded indication or justify CS. Examination of the indication recorded in
the patient's record revealed that the main indication for CS among study cases was
previous CS (table 3).

     In agreement with the present study, in Thailand in the year 2000, a study
showed that repeat CS was the most common indication in the private hospitals
(63%), and university hospital (88%) while failure to progress was the most common
indication in general hospitals (55%). (35) On the contrary, in Jordan the most common
indications were failure to progress (18.8%) while, previous CS was (13.3%). (36)

     These findings may be attributed to the possibility that physicians might still be
following the rule of “once cesarean always cesarean”. It was also found that in most
of cases with previous one CS ‘tender scar’ was reported as an indication in the
medical record denoting either previous bad surgical technique or may be a trial to
justify the operation (Table 3) and even though they didn’t take a trial of labour.
Countries in Europe achieve more than 50% of vaginal births after a prior CS
compared with 25% in the USA but in Jordan it was achieved in more than 75%.(37 )

     Fetal distress constituted the second common reported indication in the present
study (17.6%), although there was no documentation in the files to prove that (table
6). Absence of evidence might be due to non use of fetal monitor or external
cardiotocography for diagnosis of fetal distress. The diagnosis most probably
depends only on fetal heart sound for follow up of cases. Fetal distress also
contributed to an increase CS rate significantly in Jordan. The diagnosis of fetal
distress was based on the abnormal cardiotocographic (CTG) findings and the
proved severe fetal bradycardia by intermittent auscultation.           (18)   Several studies
showed that Doppler auscultation of the fetal heart, admission of cardiotocography
doesn’t benefit neonatal outcome in low risk women but its use results in increased
obstetric intervention, including operative delivery. (18, 38)

     In the present study the third common indication was failed trial and failure to
progress (11.4%), then cephalo-pelvic disproportion (10.3%, Table 3). Regarding the
cases diagnosed as failed trial and failure to progress (dystocia), there is no
documentation in patient's records for the dose of oxytocin or the progress of labor
such as partogram (table 6). The recorded causes of failure of induction were
dystocia which is the main outcome (85.1%), cephalopelvic disproportion (7.5%)
and fetal distress (6.5%, Table 5). Dystocia constituted the highest percent, which
might be due to use of inappropriate oxytocin dosage, improper follow up in the first
stage of labor, or non use of partogram. So the term dystocia might be over used as
an indication to justify the performance of CS. This was in concordance with another
study   (18)   where, significant decrease in the percentage of CS which was performed
for dystocia was reported due to more accuracy in estimation of the fetal body
weight, and with proper use of oxytocin dosage which can correct malrotation of
vertex leading to subsequent reduction in CS rate for dystocia.

     In the present study breech presentation was the main abnormal fetal
presentation. Breech presentation at term is seen in approximately 3%-4% of
pregnancies. In 1959, Wright recommended cesarean delivery for the fetus with a
breech presentation. This recommendation, along with others, led to a major change
in the management of breech presentation.        (37)   Breech presentation was the third
most important cause of the rise in cesarean delivery rate during the past 20 years.
The performance of cesarean delivery for breech presentation not only increases the
primary cesarean delivery rate but also has an impact on the total cesarean delivery
rate for the future because many women may have repeated cesarean deliveries in
subsequent pregnancies. (37)

     The general practice is still to deliver most breeches by CS regardless of the
estimated fetal weight.(18)       There is evidence that external cephalic version can
substantially change the incidence of breech presentation at delivery precluding the
need for cesarean section. So it is an effective and safe procedure and should be
included in the routine management of breech presentation.(37 ) The reported success
rate of term external cephalic version ranges from 41% to 77% with a very low
reversion rate.(37, 39)

     In light of the present findings, the following recommendations to reduce CS
rate are suggested:

   1. Every hospital that has an obstetric service should have some committee that
        examines every CS is performed in that hospital and determines whether it was
        indicated or not. If it was not indicated, then the physician who performed the
        section should be educated as to why it was not indicated.
   2. Regular monitoring of CS rate in Gamal Abdel Naser Hospital including
        indication and feed back to different units and individual physicians.
   3. Raising the awareness of the physician about:
      •     The importance of attempting vaginal delivery for patient who meets criteria for
            attempt vaginal delivery.
      •     The appropriate indications of CS.
      •     Decrease CS for breech presentation (along with more cephalic versions)
      4. Active encouragement of vaginal birth after cesarean (VBAC).
      5. An medical record form should be designed to record the CS deliveries including
          the indication as well as data to verify this indication. Completion of this form
          should be regularly monitored.

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