Research Letter
Indications for Caesarean sections in a rural hospital in the Highlands of Papua New Guinea
Tropical Doctor 2014, Vol. 44(3) 171–172 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514528899 tdo.sagepub.com
Terence B Mark1, Jim Radcliffe2 and Moses Laman3
Abstract We retrospectively documented indications for Caesarean sections in a rural district level hospital in the highlands of Papua New Guinea. Over a 53-month study period, 745 Caesarean sections were performed. Prolonged labour, previous history of Caesarean section, cephalopelvic disproportion, malpresentation and fetal distress accounted for over 88% of Caesarean sections performed. In older mothers (aged >30 years), antepartum haemorrhage (Fisher exact test, P ¼ 0.05) and multiple indications (P ¼ 0.001) were leading reasons for Caesarean sections while cephalopelvic disproportion (P ¼ 0.005) was the leading indication in younger mothers. Further prospective studies incorporating perinatal and maternal mortality rates are required to optimise the value of Caesarean sections at district level hospitals in Papua New Guinea. Keywords Caesarean sections, pregnancy, Papua New Guinea
According to the World Health Organization, an estimated 287,000 maternal deaths occurred in 2010 due to complications of childbirth.1 The majority of these deaths occurred in developing countries where basic obstetric emergency care, family planning and antenatal services are limited. An example of such a resource-limited setting is Papua New Guinea, a developing country in the Oceania region where maternal2 and perinatal3 mortality rates remain the highest in the region, with a recent survey estimating maternal mortality rates to be as high as 733/100,000 live births.4 However, even in resource-limited settings, intervention procedures like Caesarean sections are well-known to significantly reduce maternal and perinatal mortality rates.5 Despite this, there are limited guidelines to assist clinicians decide which patients should undergo this lifesaving intervention. Furthermore, regional differences may necessitate locally derived data to assist in the development of such guidelines. In Papua New Guinea, there have been no studies documenting indications for Caesarean sections at rural district level hospitals. We performed a retrospective audit of the indications for Caesarean sections at the Kudjip Nazarene Rural Hospital in Jiwaka province of Papua New Guinea for the period August 2008 to December 2012. Kudjip Nazarene Hospital is a district level hospital that serves 10 surrounding health centres. Based on the 2011 national census data, the hospital serves a
predominantly rural provincial population of approximately 340,000 and the province has an estimated annual growth rate of 5.5%. Approval for this audit was obtained from the management of Kudjip Nazarene Hospital. In the present study, statistical analyses were performed using STATA 11.0 (Stata Corp., College Station, TX, USA). Over the 53-month retrospective study period, 745 Caesarean sections were performed of which 736 had a documented indication available for analysis. The youngest mother was aged 14 years, the oldest was aged 45 years and the mean age was 26 years (standard deviation 6.2 years). Seventy-nine percent of mothers were aged 30 years. The hospital Caesarean section rate during the study period was 13%, 9% of deliveries were by vacuum extraction, and there were no cases of symphysiotomy or forceps deliveries. Of the 736 1 Surgical Registrar, Kudjip Nazarene Hospital, Mt Hagen, Papua New Guinea 2 Consultant Surgeon, Kudjip Nazarene Hospital, Mt Hagen, Papua New Guinea 3 Clinical Research Fellow, Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
Corresponding author: Moses Laman, PNG Institute of Medical Research, PO Box 378, Madang, Papua New Guinea. Email: [email protected]
172
Tropical Doctor 44(3)
Table 1. Indications for Caesarean sections performed at Kudjip Nazarene Hospital in the highlands of Papua New Guinea (August 2008 to December 2012). Indication
Frequency (n ¼ 736)
Prolonged labour Previous Caesarean section Cephalopelvic disproportion Malpresentation Fetal distress Multiple indications* Antepartum haemorrhage/ Placenta previa Cord prolapse Pre-eclampsia/ eclampsia Failed delivery PROM Oligohydramnios
185 159 127 95 86 30 20
(25.1) (21.6) (17.3) (12.9) (11.7) (4.1) (2.7)
11 10 9 3 1
(1.5) (1.4) (1.2) (0.4) (0.1)
*Denotes two or more indications for Caesarean section. PROM, premature rupture of membrane.
mothers who had a Caesarean section, 4% had it combined with sterilisation. Prolonged labour (25.1%) was the leading indication for Caesarean section followed by a previous history of Caesarean section (21.6%) and cephalopelvic disproportion (17.3%). Other indications for Caesarean section are shown in Table 1. When comparing older mothers (aged >30 years old) to younger mothers, antepartum haemorrhage (4.5% versus 1%; Fisher’s exact test P ¼ 0.05) and multiple indications (10.7% versus 2.7%; Fisher’s exact test P ¼ 0.001) were significant indications for Caesarean sections. In younger mothers, cephalopelvic disproportion (19.2% versus 9.7%; Fisher’s exact test P ¼ 0.005) was the leading indication for Caesarean sections. Eight percent of mothers were aged 18 years and these mothers were more likely to have cephalopelvic disproportion (Fisher’s exact test P ¼ 0.003). This study shows that in Jiwaka province in the highlands of Papua New Guinea, the five leading indications for Caesarean section are prolonged labour, a previous history of Caesarean section, cephalopelvic disproportion, malpresentation and fetal distress. Together, these indications accounted for over 88% of the reasons for Caesarean sections in our setting. This highlights that despite the lack of standard guidelines, identification of the common indications for Caesarean section to prevent maternal and perinatal deaths remains highly achievable even in resource-limited settings. Therefore, in order for resource-limited settings to move closer to achieving the Millennium Development Goal 5 which aims to reduce maternal deaths by three-quarters by the year 2015, improved obstetrics services need to be provided.1
The high rates of prolonged labour, fetal distress and other complications in our setting reflect the plight of mothers in developing countries where the majority of deliveries occur outside of hospital settings. In cases of village deliveries and even peripheral health centre deliveries, presentation or referral to hospital is usually done only after complications arise, often resulting in poor outcomes. Furthermore, the high rate of cephalopelvic disproportion in our setting is in direct correlation with high rates of under-age pregnancy. This highlights the need for sexual health education among young people, access to family planning and the need to advocate against cultures that promote early marriage. The present study had limitations. Because of the retrospective nature of this study, we were unable to document perinatal or maternal mortality rates during the study period. Despite this, we have achieved the aim of this study which was to identify indications for Caesarean sections in a rural hospital in the highlands of Papua New Guinea. Further prospective studies will be needed to identify indications for Caesarean sections in correlation with maternal and perinatal morbidity and mortality rates in order to develop guidelines that can optimise the value of this life-saving intervention particularly in rural district level hospitals in Papua New Guinea. Acknowledgements We thank Dr Scott Dooley for administrative assistance and the management of Kudjip Nazarene Hospital for the approval to carry out this study. We also gratefully acknowledge the nurses, doctors and theatre staff who were involved in the clinical management of these patients.
Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. World Health Organization. Trends in Maternal Mortality, 1990–2010. Geneva: WHO, 2012. 2. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609–1623. 3. Papua New Guinea Paediatric Society. Annual Morbidity and Mortality Report. Port Moresby: Papua New Guinea Paediatric Society, 2012. 4. World Health Organization. Country cooperation strategy at a glance. Geneva: WHO, 2010. 5. Weil O and Fernandez H. Is safe motherhood an orphan initiative? Lancet 1999; 354: 940–943.
Indications for Caesarean sections in a rural hospital in the Highlands of Papua New Guinea
Tropical Doctor 2014, Vol. 44(3) 171–172 ! The Author(s) 2014 Reprints and permissions: sagepub.co.uk/journalsPermissions.nav DOI: 10.1177/0049475514528899 tdo.sagepub.com
Terence B Mark1, Jim Radcliffe2 and Moses Laman3
Abstract We retrospectively documented indications for Caesarean sections in a rural district level hospital in the highlands of Papua New Guinea. Over a 53-month study period, 745 Caesarean sections were performed. Prolonged labour, previous history of Caesarean section, cephalopelvic disproportion, malpresentation and fetal distress accounted for over 88% of Caesarean sections performed. In older mothers (aged >30 years), antepartum haemorrhage (Fisher exact test, P ¼ 0.05) and multiple indications (P ¼ 0.001) were leading reasons for Caesarean sections while cephalopelvic disproportion (P ¼ 0.005) was the leading indication in younger mothers. Further prospective studies incorporating perinatal and maternal mortality rates are required to optimise the value of Caesarean sections at district level hospitals in Papua New Guinea. Keywords Caesarean sections, pregnancy, Papua New Guinea
According to the World Health Organization, an estimated 287,000 maternal deaths occurred in 2010 due to complications of childbirth.1 The majority of these deaths occurred in developing countries where basic obstetric emergency care, family planning and antenatal services are limited. An example of such a resource-limited setting is Papua New Guinea, a developing country in the Oceania region where maternal2 and perinatal3 mortality rates remain the highest in the region, with a recent survey estimating maternal mortality rates to be as high as 733/100,000 live births.4 However, even in resource-limited settings, intervention procedures like Caesarean sections are well-known to significantly reduce maternal and perinatal mortality rates.5 Despite this, there are limited guidelines to assist clinicians decide which patients should undergo this lifesaving intervention. Furthermore, regional differences may necessitate locally derived data to assist in the development of such guidelines. In Papua New Guinea, there have been no studies documenting indications for Caesarean sections at rural district level hospitals. We performed a retrospective audit of the indications for Caesarean sections at the Kudjip Nazarene Rural Hospital in Jiwaka province of Papua New Guinea for the period August 2008 to December 2012. Kudjip Nazarene Hospital is a district level hospital that serves 10 surrounding health centres. Based on the 2011 national census data, the hospital serves a
predominantly rural provincial population of approximately 340,000 and the province has an estimated annual growth rate of 5.5%. Approval for this audit was obtained from the management of Kudjip Nazarene Hospital. In the present study, statistical analyses were performed using STATA 11.0 (Stata Corp., College Station, TX, USA). Over the 53-month retrospective study period, 745 Caesarean sections were performed of which 736 had a documented indication available for analysis. The youngest mother was aged 14 years, the oldest was aged 45 years and the mean age was 26 years (standard deviation 6.2 years). Seventy-nine percent of mothers were aged 30 years. The hospital Caesarean section rate during the study period was 13%, 9% of deliveries were by vacuum extraction, and there were no cases of symphysiotomy or forceps deliveries. Of the 736 1 Surgical Registrar, Kudjip Nazarene Hospital, Mt Hagen, Papua New Guinea 2 Consultant Surgeon, Kudjip Nazarene Hospital, Mt Hagen, Papua New Guinea 3 Clinical Research Fellow, Papua New Guinea Institute of Medical Research, Madang, Papua New Guinea
Corresponding author: Moses Laman, PNG Institute of Medical Research, PO Box 378, Madang, Papua New Guinea. Email: [email protected]
172
Tropical Doctor 44(3)
Table 1. Indications for Caesarean sections performed at Kudjip Nazarene Hospital in the highlands of Papua New Guinea (August 2008 to December 2012). Indication
Frequency (n ¼ 736)
Prolonged labour Previous Caesarean section Cephalopelvic disproportion Malpresentation Fetal distress Multiple indications* Antepartum haemorrhage/ Placenta previa Cord prolapse Pre-eclampsia/ eclampsia Failed delivery PROM Oligohydramnios
185 159 127 95 86 30 20
(25.1) (21.6) (17.3) (12.9) (11.7) (4.1) (2.7)
11 10 9 3 1
(1.5) (1.4) (1.2) (0.4) (0.1)
*Denotes two or more indications for Caesarean section. PROM, premature rupture of membrane.
mothers who had a Caesarean section, 4% had it combined with sterilisation. Prolonged labour (25.1%) was the leading indication for Caesarean section followed by a previous history of Caesarean section (21.6%) and cephalopelvic disproportion (17.3%). Other indications for Caesarean section are shown in Table 1. When comparing older mothers (aged >30 years old) to younger mothers, antepartum haemorrhage (4.5% versus 1%; Fisher’s exact test P ¼ 0.05) and multiple indications (10.7% versus 2.7%; Fisher’s exact test P ¼ 0.001) were significant indications for Caesarean sections. In younger mothers, cephalopelvic disproportion (19.2% versus 9.7%; Fisher’s exact test P ¼ 0.005) was the leading indication for Caesarean sections. Eight percent of mothers were aged 18 years and these mothers were more likely to have cephalopelvic disproportion (Fisher’s exact test P ¼ 0.003). This study shows that in Jiwaka province in the highlands of Papua New Guinea, the five leading indications for Caesarean section are prolonged labour, a previous history of Caesarean section, cephalopelvic disproportion, malpresentation and fetal distress. Together, these indications accounted for over 88% of the reasons for Caesarean sections in our setting. This highlights that despite the lack of standard guidelines, identification of the common indications for Caesarean section to prevent maternal and perinatal deaths remains highly achievable even in resource-limited settings. Therefore, in order for resource-limited settings to move closer to achieving the Millennium Development Goal 5 which aims to reduce maternal deaths by three-quarters by the year 2015, improved obstetrics services need to be provided.1
The high rates of prolonged labour, fetal distress and other complications in our setting reflect the plight of mothers in developing countries where the majority of deliveries occur outside of hospital settings. In cases of village deliveries and even peripheral health centre deliveries, presentation or referral to hospital is usually done only after complications arise, often resulting in poor outcomes. Furthermore, the high rate of cephalopelvic disproportion in our setting is in direct correlation with high rates of under-age pregnancy. This highlights the need for sexual health education among young people, access to family planning and the need to advocate against cultures that promote early marriage. The present study had limitations. Because of the retrospective nature of this study, we were unable to document perinatal or maternal mortality rates during the study period. Despite this, we have achieved the aim of this study which was to identify indications for Caesarean sections in a rural hospital in the highlands of Papua New Guinea. Further prospective studies will be needed to identify indications for Caesarean sections in correlation with maternal and perinatal morbidity and mortality rates in order to develop guidelines that can optimise the value of this life-saving intervention particularly in rural district level hospitals in Papua New Guinea. Acknowledgements We thank Dr Scott Dooley for administrative assistance and the management of Kudjip Nazarene Hospital for the approval to carry out this study. We also gratefully acknowledge the nurses, doctors and theatre staff who were involved in the clinical management of these patients.
Declaration of conflicting interests None declared.
Funding This research received no specific grant from any funding agency in the public, commercial or not-for-profit sectors.
References 1. World Health Organization. Trends in Maternal Mortality, 1990–2010. Geneva: WHO, 2012. 2. Hogan MC, Foreman KJ, Naghavi M, et al. Maternal mortality for 181 countries, 1980–2008: a systematic analysis of progress towards Millennium Development Goal 5. Lancet 2010; 375: 1609–1623. 3. Papua New Guinea Paediatric Society. Annual Morbidity and Mortality Report. Port Moresby: Papua New Guinea Paediatric Society, 2012. 4. World Health Organization. Country cooperation strategy at a glance. Geneva: WHO, 2010. 5. Weil O and Fernandez H. Is safe motherhood an orphan initiative? Lancet 1999; 354: 940–943.
