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Caesarean section in four South East Asian countries: reasons for, rates, associated care practices and health outcomes

Caesarean section in four South East Asian countries: reasons for, rates, associated care... Background: Caesarean section is a commonly performed operation on women that is globally increasing in prevalence each year. There is a large variation in the rates of caesarean, both in high and low income countries, as well as between different institutions within these countries. This audit aimed to report rates and reasons for caesarean and associated clinical care practices amongst nine hospitals in the four South East Asian countries participating in the South East Asia- Optimising Reproductive and Child Health in Developing countries (SEA-ORCHID) project. Methods: Data on caesarean rates, care practices and health outcomes were collected from the medical records of the 9550 women and their 9665 infants admitted to the nine participating hospitals across South East Asia between January and December 2005. Results: Overall 27% of women had a caesarean section, with rates varying from 19% to 35% between countries and 12% to 39% between hospitals within countries. The most common indications for caesarean were previous caesarean (7.0%), cephalopelvic disproportion (6.3%), malpresentation (4.7%) and fetal distress (3.3%). Neonatal resuscitation rates ranged from 7% to 60% between countries. Prophylactic antibiotics were almost universally given but variations in timing occurred between countries and between hospitals within countries. Conclusion: Rates and reasons for caesarean section and associated clinical care practices and health outcomes varied widely between the four South East Asian countries. Background [1-5]. There is a large variation in the rates of caesarean, Caesarean section is a commonly performed operation on both in high and low income countries, as well as between women that is globally increasing in prevalence each year different institutions within these countries [3,4]. Page 1 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 In the past, recommended caesarean rates have been cal- Seven of the nine hospitals were tertiary (university and culated using various methods and concepts, the most regional) referral institutions with regional referrals of common of which is based on the number of births in a women with a high risk pregnancy and two were provin- hospital. The most widely recommended upper limit rate cial or district institutions. The hospital delivery care mod- of caesarean section was 15 percent as advocated by the els included a multidisciplinary approach with midwives World Health Organization (WHO) [6]. This was based (including nurses with midwifery qualifications) or on caesarean rates of countries with the lowest maternal obstetric specialists. Caesarean section facilities and and neonatal mortality rate at the time of the recommen- obstetric specialists were available, and doctors and/or dation, and took into account both developed and devel- midwives (including nurses with midwifery qualifica- oping countries [4,6]. Since then the World Health tions) conducted normal vaginal births in all hospitals. Organization has published a revision in 1994, stating that acceptable caesarean section rates should range Approval for the project was given by the local ethics com- between 5 and 15 percent [7]. mittee of each hospital and by the ethics committee of the University of Sydney, the administering institution in Caesarean section in developing countries is associated Australia with significant increases in maternal morbidity [4,8] par- ticularly following elective caesarean section [9] and cae- Procedure sarean section without medical indications [10]. Increases As part of the SEA-ORCHID project baseline data collec- in infant morbidity and mortality are associated with cae- tion, between January and December 2005, we previously sareans in developing countries [3,4,10]. However, in low reviewed the medical records of 9550 women and their income countries, very low caesarean rates (less than 1%) 9665 infants (including 111 twins and two sets of triplets) have been associated with higher maternal and infant admitted to the labour wards at the nine participating mortality linked to the inability to perform a caesarean hospitals. Data were collected on a consecutive basis at section when needed [4,11]. five of the participating hospitals until a total of at least 1000 women's medical records had been reviewed. Cases Interventions aimed at reducing maternal and perinatal were sampled using a variety of ratios at the four largest morbidity and mortality associated with caesarean have hospitals. This method was used to ensure data were col- included auditing of the rates, indications for and associ- lected for a minimum of three months from each hospital ated health outcomes [12,13], while interventions to and over similar time periods. reduce high caesarean rates and inappropriate caesarean practices have involved the use of best evidence such as in For the current audit, medical records were reviewed by the WHO Reproductive Health Library [14] and manda- trained staff using pre-established and piloted data extrac- tory second opinion for non-emergency caesarean section tion forms. Information about women who gave birth by [15]. caesarean section and their babies was collected. The SEA-ORCHID (South East Asia – Optimising Repro- Main indications for caesarean section were collected by ductive and Child Health in Developing countries) trained staff who selected a single main reason for caesar- project [16] across four South East Asian countries found ean section from a predetermined list (Table 1) the average rate of caesarean section to be 27% [17]. We therefore conducted this review of caesarean section prac- Other information collected from the medical record tice in hospitals within the countries participating in SEA- regarding maternal and perinatal care practice around cae- ORCHID to assess information on the rates, reasons for sarean section included prophylactic antibiotic use and and care practices associated with caesarean. We also estimated blood loss for women having a caesarean sec- looked at the pregnancy background of women and tion (Table 2) and use of antibiotics during postnatal care health outcomes for women who had a caesarean and for women (Table 3). their babies. Health outcomes for infants born by caesarean section were collected and included gestational age at birth, birth Methods Setting weight, need for resuscitation, low Apgar scores at 1 and 5 Nine hospitals participating in the SEA-ORCHID project minutes, stillbirth, babies born alive who later died and representing different types of hospitals across four coun- total death rates (Table 4). tries in South East Asia (Indonesia, Malaysia, The Philip- pines and Thailand) were audited, with support from Trained fieldworkers used a secure web-based database to three sites in Australia [17]. The SEA-ORCHID project set- manually enter the data. The online form allowed valida- tings and methods have been published elsewhere [16]. tion checks to be performed to detect discrepancies and Page 2 of 11 (page number not for citation purposes) Table 1: Rates and main indications for caesarean section (as percentage of overall births and percentages of rates consecutively) Indonesia Malaysia The Thailand Philippines Overall Tertiary District Overall Tertiary 1 Tertiary 2 Overall Tertiary 1 Tertiary 2 Overall Regional University Provincial n = 2086 n = 1019 n = 1067 n = 2379 n = 1249 n = 1130 n = 2085 n = 1026 n = 1059 n = 3000 n = 1000 n = 1000 n = 1000 Rate of caesarean 29.6 28.7 30.6 19.1 21.1 16.8 22.7 12.3 32.9 34.8 33.3 33.2 38.0 section Indication for caesarean section Malpresentations 5.5 3.8 7.1 5.0 5.4 4.6 3.9 2.5 5.3 4.5 5.5 3.8 4.3 Previous 4.5 3.0 5.8 3.3 3.5 3.1 10.1 6.6 13.4 9.7 8.8 9.3 11.0 caesarean section Cephalopelvic 3.8 2.0 5.5 4.8 5.4 4.2 3.0 1.3 4.6 11.4 9.7 9.3 15.2 disproportion Fetal distress 3.3 4.0 2.6 3.3 3.8 2.7 2.0 0.3 3.7 4.2 5.2 3.8 3.7 Failure to 3.4 4.3 2.4 0.0 0.0 0.0 0.0 0.0 0.0 0.7 0.2 1.4 0.6 progress Antepartum 2.5 2.5 2.5 1.2 1.2 1.2 1.7 1.0 2.5 0.6 0.8 0.6 0.5 haemorrhage Pre-eclampsia/ 2.2 3.2 1.1 0.0 0.0 0.0 0.0 0.0 0.0 0.7 1.1 0.4 0.7 eclampsia Maternal request 2.1 3.7 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Premature 1.6 1.0 2.2 0.0 0.0 0.0 0.0 0.0 0.0 0.3 0.2 0.3 0.3 rupture of membranes Other Maternal 0.4 0.4 0.5 0.7 1.0 0.4 1.0 0.0 1.9 1.4 0.6 2.9 0.8 conditions Multiple 0.0 0.0 0.0 0.1 0.1 0.2 0.2 0.1 0.3 0.7 0.6 0.6 0.9 pregnancy Other 0.4 0.7 0.2 0.5 0.6 0.4 0.9 0.5 1.2 0.5 0.6 0.8 0.0 Figures are percentage rounded to one decimal point BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Page 3 of 11 (page number not for citation purposes) Table 2: Use of prophylactic antibiotics and blood loss for women having a caesarean section (as percentage of caesarean deliveries) Indonesia Malaysia The Thailand Philippines Overall Tertiary District Overall Tertiary 1 Tertiary 2 Overall Tertiary 1 Tertiary 2 Overall Regional University Provincial n = 618 n = 292 n = 326 n = 453 n = 264 n = 189 n = 474 n = 126 n = 348 n = 1045 n = 333 n = 332 n = 380 Antibiotics 100 100 100 99 100 98 93 100 91 100 10099100 given If yes, when given pre-operatively 0 00 60 100 4 58 99 41 9 21 2 6 after cord 0 00 1 01 12 116 88 78 99 87 clamped post- 100 100 100 39 095 31 0 43 3 10 7 operatively If given, which antibiotics cephalosporin 77 69 84 59 100 1 73 82 69 84 76 94 83 ampicillin 7 15 0 37 090 4 53 13 22 5 11 other 16 16 16 4 09 23 14 27 3 21 6 If given, what dosage single 0 00 59 100 0 76 93 70 53 82 84 1 multiple 100 100 100 41 0100 24 730 47 18 16 99 Blood loss at caesarean section < = 500 mls 96 95 97 74 70 80 21 35 17 67 72 43 83 501 – 1000 mls 4 53 19 22 14 75 62 80 32 26 56 17 ≥ 1000 mls 0 00 7 86 4 34 1 21 0 Postpartum 4 53 26 30 20 79 65 83 33 28 57 17 haemorrhage > 500 ml Postpartum 5 46 9 810 4 34 1 11 0 transfusion Figures are percentage rounded to the nearest whole number BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Page 4 of 11 (page number not for citation purposes) Table 3: Use of antibiotics during postnatal care for women (as percentage of caesarean deliveries) Indonesia Malaysia The Thailand Philippines Overall Tertiary District Overall Tertiary 1 Tertiary 2 Overall Tertiary 1 Tertiary 2 Overall Regional University Provincial n = 619 n = 292 n = 327 n = 454 n = 264 n = 190 n = 474 n = 126 n = 348 n = 1045 n = 333 n = 332 n = 380 Antibiotics 100 100 100 41 394 54 98 38 48 24 15 97 postpartum If yes, antibiotics given for Prophylaxis 100 100 100 90 093 36 069 90 71 67 97 Wound 0 00 0 00 52 98 8 0 14 0 infection Preterm 0 00 6 43 4 0 00 4 11 4 2 prelabour rupture of membranes Urinary tract 0 00 2 43 0 0 00 1 14 0 infection Endometritis 0 00 2 14 1 0 00 2 48 1 Upper 0 00 1 01 0 10 1 64 0 respiratory tract infection Other/ 0 00 1 01 12 122 2 68 0 Unknown Figures are percentage rounded to the nearest whole number BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Page 5 of 11 (page number not for citation purposes) Table 4: Health outcomes for infants who were born by caesarean section (as percentage of caesarean born babies) Indonesia Malaysia The Thailand Philippines Overall Tertiary District Overall Tertiary 1 Tertiary 2 Overall Tertiary 1 Tertiary 2 Overall Regional University Provincial n = 628 n = 294 n = 334 n = 465 n = 272 n = 193 n = 479 n = 126 n = 353 n = 1074 n = 342 n = 342 n = 390 Stillbirth 1.0 2.0 0.0 0.9 0.4 1.6 0.2 0.8 0.0 0.4 0.0 0.6 0.5 Babies born 0.3 0.0 0.6 0.4 0.4 0.5 0.4 0.8 0.3 1.1 0.9 1.5 1.0 alive who died # Total deaths 1.3 2.0 0.6 1.3 0.7 2.1 0.6 1.6 0.3 1.5 0.9 2.0 1.5 Gestational 38.8 38.3 39.2 37.9 37.8 38.3 37.8 38.1 37.7 38.3 37.9 38.1 38.8 age at birth (2.2) (2.7) (1.4) (2.0) (2.2) (1.7) (2.1) (1.5) (2.2) (2.2) (2.3) (2.3) (2.0) (weeks) * Gestational 10 18 3 13 15 11 10 312 12 16 13 9 age at birth < 37 weeks Birth weight 2.97 2.87 3.01 3.02 3.0 3.05 2.8 2.89 2.76 3.06 3.0 3.1 3.13 (kg) * (0.65) (0.74) (0.56) (0.70) (0.71) (0.69) (0.60) (0.48) (0.63) (0.60) (0.58) (0.63) (0.57) very low birth 3 51 3 33 3 14 2 23 1 weight (< 1500 g) low birth 16 20 13 15 15 15 21 15 24 10 16 8 7 weight (1500–2499 g) normal 77 70 83 74 74 75 75 85 71 84 79 86 87 (2500–4499 g) macrosomia 5 54 8 78 1 01 4 43 5 (≥ 4000 g) Resuscitation 43 40 46 7 510 16 19 15 60 21 57 97 Apgar 35 42 28 8 79 9 810 6 77 4 score < 7 at 1 min Apgar 9 14 5 2 23 3 24 2 22 2 score < 7 at 5 min Figures are percentage rounded to the nearest whole number, or percentagerounded to one decimal point or *mean (standard deviation) Calculated for live births only BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Page 6 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 missing data and thus ensured transcription errors were operatively almost universally, while in the other hospital minimized. 41% of mothers received antibiotics pre-operatively and 43% post-operatively, with the remainder given intra- Data analysis operatively after umbilical cord clamping. In Thailand Data analysis was performed using STATA software Ver- almost 90% of women were given prophylactic antibiotics sion 8.0 [18]. Descriptive analysis was performed between intra-operatively after umbilical cord clamping, with the hospitals within countries as well as across countries. For next most common time of administration being pre- categorical data, frequencies were used to describe mater- operatively. nal characteristics, maternal and perinatal care practices and birth outcomes. For continuous data, means and Cephalosporin was the most common class of prophylac- standard deviations (SDs) were used. tic antibiotics used across all hospitals with a rate of 73%. Ampicillin was the next most commonly used antibiotic Ethics Approval in Malaysia and Thailand, while 'other' antibiotics were The SEA-ORCHID project was approved by the local eth- the next most common in Indonesia and The Philippines. ics committees of each hospital and by the ethics commit- The frequency of dose for prophylactic antibiotics varied tee of the University of Sydney, the administering both between countries and between hospitals in coun- institution in Australia. tries. Mothers in Indonesia received multiple doses of pro- phylactic antibiotics while mothers in Malaysia received Results either a single dose or multiple doses depending on their Of the 9550 women, 2592 (27%) women and their 2645 births or the hospital. In The Philippines and Thailand (27%) babies were born by caesarean. Actual rates varied rates ranged from 1% to 93% for single doses of prophy- from 12% to 39% between hospitals and from 19% to lactic antibiotics and from 7% to 99% for multiple doses. 35% between countries (Table 1). Caesarean section and blood loss (Table 2) Rates and indications for caesarean section (Table 1) In Indonesia, Malaysia, and Thailand, the majority of The most common indications for caesarean were malpre- women were reported to have a less than 500 ml esti- sentation, previous caesarean section, cephalopelvic dis- mated blood loss, while in the Philippines 79% were esti- proportion, and fetal distress. In Indonesia and Malaysia, mated to have a greater than 500 ml blood loss. The the most common indication was malpresentation with reported postpartum haemorrhage rate > 500 ml for Indo- rates of 5.5% and 5.0% respectively. In The Philippines, nesia was only 4%. Malaysia reported the highest rate for caesarean in a previous pregnancy was the most common postpartum maternal transfusion (9%). indication for a caesarean for mothers who gave birth again (10.1%), while cephalopelvic disproportion was the Postnatal care after caesarean section (Table 3) most frequent indication in Thailand (11.4%). Mothers were often given prophylactic antibiotics postna- tally with rates varying between countries and between Common pregnancy complications such as preeclampsia hospitals within countries. All mothers in Indonesia were and antepartum haemorrhage were not often given as given prophylactic antibiotics postnatally. Rates varied indications for caesarean. Although maternal request for a widely between hospitals in Malaysia (3% and 94%), The caesarean was relatively frequent in one of the tertiary Philippines (38% and 98%) and Thailand (15% to 97%). hospitals in Indonesia (3.7%), this was not an indication The main reason for giving antibiotics postnatally to in Malaysia, Thailand and The Philippines. women was prophylaxis and this was commonly prac- ticed in Indonesia (100%), Thailand (90%) and Malaysia Prophylactic antibiotic use for mothers who gave birth by (90%), although it was less common in The Philippines caesarean section (Table 2) (36%) where wound infection was the main reason Prophylactic antibiotics were almost universally given reported (52%) for postnatal antibiotic administration. across all four countries in South East Asia, with only one Birth and infant health outcomes (Table 4) tertiary hospital in The Philippines reporting a slightly lower rate of 91%. There was variation in the timing of The mean gestational age at birth of babies born by cae- prophylactic antibiotics, both between countries and sarean across the hospitals was similar (range 37.7 (SD between hospitals within countries. In Indonesia, prophy- 2.2) to 39.2 (SD 1.4) weeks). The preterm birth rate (< 37 lactic antibiotics were universally given post-operatively. weeks gestation) varied widely from 3% to 18% between In one Malaysian hospital they were always given pre- hospitals although similar from 10% to 13% between operatively, while in the other they were given post-oper- countries. Overall, 16% of the babies born by caesarean atively 95% of the time. In one hospital in The Philip- were of low birth weight (< 2500 g), with rates ranging pines, mothers were given prophylactic antibiotics pre- from 8% to 28% between hospitals. The mean birth Page 7 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 weight of babies ranged from 2.76 kg (SD 0.63) to 3.13 kg fore we consider misclassification unlikely to account for (SD 0.57) between hospitals and 2.8 kg (SD 0.60) to 3.06 variation between institutions. kg (SD 0.60) between countries. Previous caesarean section as an indication for caesarean There were wide variations in the use of neonatal resusci- section is not a recommendation of the NCCWCH/RCOG tation at caesarean. Babies born by caesarean in Thailand UK guidelines [2]. The high incidence of this as an indica- received resuscitation in 60% of cases, however actual tor for caesarean section in the four South East Asian rates varied widely between hospitals, ranging from 21% countries could be due to women or providers choosing in the regional hospital to 97% in the provincial hospital. this option after a previous complicated birth; a scenario In Malaysia, only 7% of babies born by caesarean received more common in developing countries [20]. In addition, resuscitation. Rates of babies with Apgar scores < 7 at 5 women may not be fully informed and educated about minutes were higher in the two Indonesian hospitals vaginal birth and associated pain and management [21]. compared with hospitals in the other three South East High caesarean rates may be attributed to limited knowl- Asian countries (5% and 12% compared with range 1% to edge and training of health professionals in developing 4%). countries causing limited implementation of recommen- dations such as vaginal birth after caesarean (VBAC). It is The rates for caesarean section where the baby was still- known that maternal morbidity particularly increases fol- born ranged between 0% to 1% between countries and lowing elective caesarean section [9] and caesarean sec- 0% to 2% between hospitals within countries. The rates tion without medical indications [10] in developing for babies born alive by caesarean who then died were countries. It is known that VBAC is an option provided the reported as 0% overall for Indonesia, Malaysia and The details of the previous caesarean are available and there is Philippines, with these three countries recording a rate of close monitoring during labour with the ability to pro- 1% in one hospital each, while Thailand recorded a rate of ceed to an emergency caesarean if needed [22,23]. 1% in all hospitals as well as overall. Other NCCWCH/RCOG-recommended indicators for Discussion caesarean section including multiple pregnancy, mother Caesarean section rates in South East Asian countries to child transmission of disease, maternal request, pla- Actual caesarean rates in developing countries, including centa praevia and preterm or small for gestational age [2] South East Asia, are largely unknown because of a lack of were reported as minimal indicators for caesarean section reliable data. Our results showed the overall caesarean in the South East Asian hospitals audited. rates, for all hospitals and all countries in the audit, to be 27%, higher than the WHO recommended rates of Use of antibiotic prophylactic between 5 and 15 percent [7]. This may be attributable to The use of prophylactic antibiotics is recommended to the fact that most of the hospitals audited were referral reduce endometritis and wound infection after elective or centres, meaning a higher proportion of women with non-elective caesarean section [24]. This knowledge has complications from other lower category hospitals would been applied in all hospitals of the four South East Asian have been sent to these hospitals. Some of the variation in countries audited, where prophylactic antibiotics were caesarean section rates between hospitals may be related almost always given. to differing maternal characteristics. Regardless, the cae- sarean rates in the South East Asian countries and hospi- Evidence suggests that prophylactic antibiotics should be tals audited are higher than the nationally representative administered pre-operatively to result in the lowest risk of data available [19]. surgical wound infection [24]. The variation in timing of antibiotic prophylactic administration between hospitals, Main indications for caesarean section and the lack of consistent timing in relation to the type of Women in the four South East Asian countries audited institution may suggest that some individual hospitals were more likely to have a caesarean if they or their infant have developed standardized policies for use of antibiotic experienced malpresentation, previous caesarean section, prophylactics, while some individual health professionals cephalopelvic disproportion or fetal distress. The may practice in line with their own preferences at other National Collaborating Centre for Women's and Chil- hospitals. dren's Health (NCCWCH) with The Royal College of Obstetricians and Gynaecologists (RCOG) [2] guidelines First generation cephalosporin and ampicillin have been list malpresentation, cephalopelvic disproportion and found to be equally effective agents for antibiotic prophy- fetal distress as main indicators for caesarean section, con- laxis for women who underwent a caesarean [25] and this sistent with the indications in our population. Trained recommendation was followed in nearly 90% of all cases staff coded the main reasons for caesarean section, there- reviewed in the four South East Asian countries. Page 8 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Multiple doses of prophylactic antibiotics have been received blood transfusions. Postnatal care for mothers found no more effective than a single dose [25] and are varied widely between hospitals within countries and also more expensive. It is therefore of interest that our review across countries. found that all mothers who underwent caesarean in Indo- nesia, in one hospital in Malaysia and in one hospital in Competing interests Thailand, were given multiple doses. Current evidence The authors declare that they have no competing interests. does not support this expensive practice. Authors' contributions Advantages and limitations of the study MF, DHS and CC contributed to the design of the study. There is lack of completeness of reporting for deaths and ML and PP cleaned and analysed the data and all authors infection within South East Asian hospitals. The reporting contributed to the interpretation of data. ME prepared the may be improved for certain outcomes that may be con- first draft of the paper. All authors commented on each sidered as important quality control or assurance indica- draft of the paper. tors for health care. Many of the SEA-ORCHID data indicators may be recommended for such purpose. The Acknowledgements The SEA-ORCHID study is jointly funded by an International Collaborative health indicators used were clearly defined and dedicated Research Grant from the National Health and Medical Research Council of data staff were trained in their collection. The variation in Australia (No. 307703) and Wellcome Trust, United Kingdom (071672/Z/ care practices seen such as for use of resuscitation of the 03/Z). All authors were funded individually by their respective university/ newborn at caesarean section, are likely to reflect different institution for the preparation of the project proposal. hospital policies as well as differences in casemix. The following persons and institutions participated in the SEA-ORCHID Adherence to best practice recommendations Study Group. Within nine hospitals in four South East Asian countries, Project Investigators: our audit has shown varying and non-structured uptake of evidence-based clinical guidelines and recommendations P. Lumbiganon, MR. Festin, JJ. Ho, M Hakimi, DJ. Henderson-Smart, S. in relation to caesarean section. This may be due to lack of Green and CA. Crowther availability and access to medical journals and reviews and therefore limited dissemination of evidence-based Project Coordinators: guidelines and recommendations. Availability of access and enablers and barriers to uptake of evidence based SJ. McDonald, M. Laopaiboon guidelines need to be examined at individual institutions. Project Administrators: The SEA-ORCHID study plans to conduct a survey of evi- dence-based practice knowledge and clinical change M. Murano, N. Narash among maternal and infant health practitioners in South East Asia to explore this issue [16]. It would be of benefit Data collection and entry at participating hospitals: for each institution to develop policies regarding caesar- ean, and particularly the timing and dosing of administra- INDONESIA tion of prophylactic antibiotics so as to encourage Country Investigator: M. Hakimi standardized practice and to reinforce that access to knowledge and information is important. Dr Sardjito Hospital, Yogyakarta, Indonesia Conclusion Data collection: Supiyah. The baseline rates of caesarean section, associated clinical practices and outcomes varied considerably in nine hospi- Data entry: L. Amanah, D. Lukitasari and D. Astuti tals of four South East Asian countries comprising Thai- Sleman District Hospital, Yogyakarta, Indonesia land, The Philippines, Malaysia and Indonesia. The most common indications for caesarean delivery were malpre- Data collection: L. Amanah sentation, previous caesarean section, cephalopelvic dis- proportion, and fetal distress. Maternal request remained Data entry: L. Amanah, D. Lukitasari and D. Astuti rare. Giving prophylactic antibiotics was nearly universal, MALAYSIA with variations in the timing of administration, (either pre-operatively, after cord clamping, or post-operatively), Country Investigator: JJ. Ho and variation also in the class and number of doses of antibiotics given. Blood loss during caesarean was com- Ipoh Hospital, Perak, Malaysia monly estimated to be less then 500 ml. A few women Page 9 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Data collection: SS. Cham 3. Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A, Shah A, Campodonico L, Bataglia V, Faundes A, Langer A, Narvaez A, Donner A, Romero M, Reynoso S, Simonia de Padua K, Giordano D, Data entry: SS. 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Hofmeyr G, Say L, Gulmezoglu A: WHO systematic review of Data collection: B. Khianman, A. Pharprapa, J. Nachaipet maternal mortality and morbidity: the prevalence of uterine rupture. BJOG 2005, 112:1221-1228. Data entry: N. Narash and R. Poombankor 9. Oladapo O, Lamina M, Sule-Odu A: Maternal morbidity and mor- tality associated with elective caesarean delivery at a univer- sity hospital in Nigeria. Aust N Z J Obst Gynaecol 2007, Khon Kaen Regional Hospital, Khon Kaen, Thailand 47(2):110-114. 10. MacDorman M, Declercq E, Menacker F, Malloy M: Infant and neo- Data collection: B. Saenrien, N. Srisutthikamol, S. Panikom, C. Khunudom, natal mortality for primary caesarean and vaginal births to S. Thipawat, S. Choonhapran, S. Nuanbuddee, P. Jarudphan, A. Hempira women with "no indicated risk". United States, 1998–2001 birth cohorts. Birth 2006, 33:175-182. 11. Ronsmans C, Holtz S, Stanton C: Socioeconomic differentials in Data entry: N. Narash and R. Poombankor caesarean rates in developing countries: a retrospective analysis. Lancet 2006, 368:1516-1523. Srinagarind Khon Kaen Univeristy Hospital, Khon Kaen, Thailand 12. Holtz S, Stanton C: Assessing the quality of caesarean birth data in the Demographic and Health Surveys. Stud Fam Plann Data collection: P. Tharnprisan, P. Sarapon, O. Ponpun 2007, 38:47-54. 13. Huskins WC, Ba-Thike K, Festin MR, Limpongsanurak S, Lumbiganon P, Peedicayil A, Purwar M, Shenoy S, Goldmann DA, Tolosa JE, Global Data entry: N. Narash and R. Poombankor Network for Perinatal and Reproductive Health: An international survey of practice variation in the use of antibiotic prophy- THE PHILIPPINES laxis in cesarean section. Int J Gynaecol Obstet 2001, 73(2):141-5. 14. Gulmezoglu A, Langer A, Piaggio G, Lumbiganon P, Cillar J, Grim- shawd J: Cluster randomised trial of an active, multifaceted Country Investigator: MR. Festin educational intervention based on the WHO Reproductive Health Library to improve obstetric practices. BJOG 2007, Jose Fabella Hospital, Manila, Philippines 114:16-23. 15. Althabe F, Belizán J, Villar J, Alexander S, Bergel E, Ramos S, Romero M, Donner A, Lindmark G, Langer A, Farnot U, Cecatti JG, Carroli G, Data collection: C. Ubaldo-Anzures and LN. Canete Kestler E, Latin American Caesarean Section Study Group: Manda- tory second opinion to reduce rates of unnecessary caesar- Data entry: J. Magsipoc and JL. Festin ean sections in Latin America: a cluster randomised controlled trial. Lancet 2004, 363:1934-1940. Philippines General Hospital (University of the Philippines), Manila, 16. Henderson-Smart DJ, Lumbiganon P, Festin MR, Ho JJ, Mohammad H, McDonald SJ, Green S, Crowther CA, for the SEA-ORCHID Study Philippines Group: Optimising reproductive and child health outcomes by building evidence-based research and practice in South Data collection: E. Torralba and LN. Canete East Asia (SEA-ORCHID): study protocol. BMC Med Res Meth- odol 2007, 7:43. Data entry: J. Magsipoc and JL. Festin 17. The SEA-ORCHID Study Group: Use of Evidence-Based Prac- tices in Pregnancy and Childbirth: South East Asia Optimis- ing Reproductive and Child Health in Developing Countries AUSTRALIA Project. PLoS ONE 2008, 3(7):e2646. 18. StataCorp: Stata Statistical Software: Release 8. College Sta- Country Investigators: D. Henderson-Smart, S. Green, CA. Crowther tion. TX: Stata Corp LP; 2003. 19. Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, Wagner M: Rates of caesarean section: analysis of global, Project Coordinator: SJ. McDonald. regional and national estimates. Paediatr Perinat Epidemiol 2007, 21:98-113. References 20. Kwawukume EY: Caesarean section in developing countries. 1. Onsrud L, Onsrud M: Increasing use of caesarean section, even Best Pract Res Clin Obstet Gynaecol 2001, 15(1):B165-178. in developing countries. Tidsskr Nor Laegeforen 1996, 21. Tangcharoensathien V, Lertiendumrong J, Hanvaoravongchai A, Ben- 116(1):67-71. nett S: Caesarean deliveries in Thailand: cause for concern. 2. National Collaborating Centre for Women's and Children's Health: Regional Health Forum, WHO South-East Asia Region 2007, 6(2): [http:/ Caesarean section: Clinical Guideline. London: RCOG Press; /www.searo.who.int/EN/Section1243/Section1310/Section1343/ 2004. Section1344/Section1356_5321.htm]. Page 10 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 22. Royal College of Obstetricians and Gynaecologists (RCOG): Birth after previous caesarean birth. 2007 [http://www.rcog.org.uk/ womens-health/clinical-guidance/birth-after-previous- caesarean- birth-green-top-45]. UK: Guidelines and Audit Committee RCOG 23. American College of Obstetricians and Gynecologists (ACOG): Vag- inal birth after previous caesarean delivery. 2004 [http:www.guideline.gov/summary/sum mary.aspx?doc_id=6374&nbr=4043&ss=15]. Washington (DC): American College of Obstetricians and Gynecologists (ACOG) 24. Smaill F, Hofmeyr G: Antibiotic prophylaxis for caesarean sec- tion. Cochrane Database Syst Rev 2002:CD000933. 25. Hopkins L, Smaill F: Antibiotic prophylaxis regimens and drugs for caesarean section. Cochrane Database Syst Rev 1999:CD001136. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2393/9/17/prepub Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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Caesarean section in four South East Asian countries: reasons for, rates, associated care practices and health outcomes

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Springer Journals
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Copyright © 2009 by Festin et al; licensee BioMed Central Ltd.
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Medicine & Public Health; Reproductive Medicine; Maternal and Child Health; Gynecology
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10.1186/1471-2393-9-17
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19426513
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Abstract

Background: Caesarean section is a commonly performed operation on women that is globally increasing in prevalence each year. There is a large variation in the rates of caesarean, both in high and low income countries, as well as between different institutions within these countries. This audit aimed to report rates and reasons for caesarean and associated clinical care practices amongst nine hospitals in the four South East Asian countries participating in the South East Asia- Optimising Reproductive and Child Health in Developing countries (SEA-ORCHID) project. Methods: Data on caesarean rates, care practices and health outcomes were collected from the medical records of the 9550 women and their 9665 infants admitted to the nine participating hospitals across South East Asia between January and December 2005. Results: Overall 27% of women had a caesarean section, with rates varying from 19% to 35% between countries and 12% to 39% between hospitals within countries. The most common indications for caesarean were previous caesarean (7.0%), cephalopelvic disproportion (6.3%), malpresentation (4.7%) and fetal distress (3.3%). Neonatal resuscitation rates ranged from 7% to 60% between countries. Prophylactic antibiotics were almost universally given but variations in timing occurred between countries and between hospitals within countries. Conclusion: Rates and reasons for caesarean section and associated clinical care practices and health outcomes varied widely between the four South East Asian countries. Background [1-5]. There is a large variation in the rates of caesarean, Caesarean section is a commonly performed operation on both in high and low income countries, as well as between women that is globally increasing in prevalence each year different institutions within these countries [3,4]. Page 1 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 In the past, recommended caesarean rates have been cal- Seven of the nine hospitals were tertiary (university and culated using various methods and concepts, the most regional) referral institutions with regional referrals of common of which is based on the number of births in a women with a high risk pregnancy and two were provin- hospital. The most widely recommended upper limit rate cial or district institutions. The hospital delivery care mod- of caesarean section was 15 percent as advocated by the els included a multidisciplinary approach with midwives World Health Organization (WHO) [6]. This was based (including nurses with midwifery qualifications) or on caesarean rates of countries with the lowest maternal obstetric specialists. Caesarean section facilities and and neonatal mortality rate at the time of the recommen- obstetric specialists were available, and doctors and/or dation, and took into account both developed and devel- midwives (including nurses with midwifery qualifica- oping countries [4,6]. Since then the World Health tions) conducted normal vaginal births in all hospitals. Organization has published a revision in 1994, stating that acceptable caesarean section rates should range Approval for the project was given by the local ethics com- between 5 and 15 percent [7]. mittee of each hospital and by the ethics committee of the University of Sydney, the administering institution in Caesarean section in developing countries is associated Australia with significant increases in maternal morbidity [4,8] par- ticularly following elective caesarean section [9] and cae- Procedure sarean section without medical indications [10]. Increases As part of the SEA-ORCHID project baseline data collec- in infant morbidity and mortality are associated with cae- tion, between January and December 2005, we previously sareans in developing countries [3,4,10]. However, in low reviewed the medical records of 9550 women and their income countries, very low caesarean rates (less than 1%) 9665 infants (including 111 twins and two sets of triplets) have been associated with higher maternal and infant admitted to the labour wards at the nine participating mortality linked to the inability to perform a caesarean hospitals. Data were collected on a consecutive basis at section when needed [4,11]. five of the participating hospitals until a total of at least 1000 women's medical records had been reviewed. Cases Interventions aimed at reducing maternal and perinatal were sampled using a variety of ratios at the four largest morbidity and mortality associated with caesarean have hospitals. This method was used to ensure data were col- included auditing of the rates, indications for and associ- lected for a minimum of three months from each hospital ated health outcomes [12,13], while interventions to and over similar time periods. reduce high caesarean rates and inappropriate caesarean practices have involved the use of best evidence such as in For the current audit, medical records were reviewed by the WHO Reproductive Health Library [14] and manda- trained staff using pre-established and piloted data extrac- tory second opinion for non-emergency caesarean section tion forms. Information about women who gave birth by [15]. caesarean section and their babies was collected. The SEA-ORCHID (South East Asia – Optimising Repro- Main indications for caesarean section were collected by ductive and Child Health in Developing countries) trained staff who selected a single main reason for caesar- project [16] across four South East Asian countries found ean section from a predetermined list (Table 1) the average rate of caesarean section to be 27% [17]. We therefore conducted this review of caesarean section prac- Other information collected from the medical record tice in hospitals within the countries participating in SEA- regarding maternal and perinatal care practice around cae- ORCHID to assess information on the rates, reasons for sarean section included prophylactic antibiotic use and and care practices associated with caesarean. We also estimated blood loss for women having a caesarean sec- looked at the pregnancy background of women and tion (Table 2) and use of antibiotics during postnatal care health outcomes for women who had a caesarean and for women (Table 3). their babies. Health outcomes for infants born by caesarean section were collected and included gestational age at birth, birth Methods Setting weight, need for resuscitation, low Apgar scores at 1 and 5 Nine hospitals participating in the SEA-ORCHID project minutes, stillbirth, babies born alive who later died and representing different types of hospitals across four coun- total death rates (Table 4). tries in South East Asia (Indonesia, Malaysia, The Philip- pines and Thailand) were audited, with support from Trained fieldworkers used a secure web-based database to three sites in Australia [17]. The SEA-ORCHID project set- manually enter the data. The online form allowed valida- tings and methods have been published elsewhere [16]. tion checks to be performed to detect discrepancies and Page 2 of 11 (page number not for citation purposes) Table 1: Rates and main indications for caesarean section (as percentage of overall births and percentages of rates consecutively) Indonesia Malaysia The Thailand Philippines Overall Tertiary District Overall Tertiary 1 Tertiary 2 Overall Tertiary 1 Tertiary 2 Overall Regional University Provincial n = 2086 n = 1019 n = 1067 n = 2379 n = 1249 n = 1130 n = 2085 n = 1026 n = 1059 n = 3000 n = 1000 n = 1000 n = 1000 Rate of caesarean 29.6 28.7 30.6 19.1 21.1 16.8 22.7 12.3 32.9 34.8 33.3 33.2 38.0 section Indication for caesarean section Malpresentations 5.5 3.8 7.1 5.0 5.4 4.6 3.9 2.5 5.3 4.5 5.5 3.8 4.3 Previous 4.5 3.0 5.8 3.3 3.5 3.1 10.1 6.6 13.4 9.7 8.8 9.3 11.0 caesarean section Cephalopelvic 3.8 2.0 5.5 4.8 5.4 4.2 3.0 1.3 4.6 11.4 9.7 9.3 15.2 disproportion Fetal distress 3.3 4.0 2.6 3.3 3.8 2.7 2.0 0.3 3.7 4.2 5.2 3.8 3.7 Failure to 3.4 4.3 2.4 0.0 0.0 0.0 0.0 0.0 0.0 0.7 0.2 1.4 0.6 progress Antepartum 2.5 2.5 2.5 1.2 1.2 1.2 1.7 1.0 2.5 0.6 0.8 0.6 0.5 haemorrhage Pre-eclampsia/ 2.2 3.2 1.1 0.0 0.0 0.0 0.0 0.0 0.0 0.7 1.1 0.4 0.7 eclampsia Maternal request 2.1 3.7 0.6 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 Premature 1.6 1.0 2.2 0.0 0.0 0.0 0.0 0.0 0.0 0.3 0.2 0.3 0.3 rupture of membranes Other Maternal 0.4 0.4 0.5 0.7 1.0 0.4 1.0 0.0 1.9 1.4 0.6 2.9 0.8 conditions Multiple 0.0 0.0 0.0 0.1 0.1 0.2 0.2 0.1 0.3 0.7 0.6 0.6 0.9 pregnancy Other 0.4 0.7 0.2 0.5 0.6 0.4 0.9 0.5 1.2 0.5 0.6 0.8 0.0 Figures are percentage rounded to one decimal point BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Page 3 of 11 (page number not for citation purposes) Table 2: Use of prophylactic antibiotics and blood loss for women having a caesarean section (as percentage of caesarean deliveries) Indonesia Malaysia The Thailand Philippines Overall Tertiary District Overall Tertiary 1 Tertiary 2 Overall Tertiary 1 Tertiary 2 Overall Regional University Provincial n = 618 n = 292 n = 326 n = 453 n = 264 n = 189 n = 474 n = 126 n = 348 n = 1045 n = 333 n = 332 n = 380 Antibiotics 100 100 100 99 100 98 93 100 91 100 10099100 given If yes, when given pre-operatively 0 00 60 100 4 58 99 41 9 21 2 6 after cord 0 00 1 01 12 116 88 78 99 87 clamped post- 100 100 100 39 095 31 0 43 3 10 7 operatively If given, which antibiotics cephalosporin 77 69 84 59 100 1 73 82 69 84 76 94 83 ampicillin 7 15 0 37 090 4 53 13 22 5 11 other 16 16 16 4 09 23 14 27 3 21 6 If given, what dosage single 0 00 59 100 0 76 93 70 53 82 84 1 multiple 100 100 100 41 0100 24 730 47 18 16 99 Blood loss at caesarean section < = 500 mls 96 95 97 74 70 80 21 35 17 67 72 43 83 501 – 1000 mls 4 53 19 22 14 75 62 80 32 26 56 17 ≥ 1000 mls 0 00 7 86 4 34 1 21 0 Postpartum 4 53 26 30 20 79 65 83 33 28 57 17 haemorrhage > 500 ml Postpartum 5 46 9 810 4 34 1 11 0 transfusion Figures are percentage rounded to the nearest whole number BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Page 4 of 11 (page number not for citation purposes) Table 3: Use of antibiotics during postnatal care for women (as percentage of caesarean deliveries) Indonesia Malaysia The Thailand Philippines Overall Tertiary District Overall Tertiary 1 Tertiary 2 Overall Tertiary 1 Tertiary 2 Overall Regional University Provincial n = 619 n = 292 n = 327 n = 454 n = 264 n = 190 n = 474 n = 126 n = 348 n = 1045 n = 333 n = 332 n = 380 Antibiotics 100 100 100 41 394 54 98 38 48 24 15 97 postpartum If yes, antibiotics given for Prophylaxis 100 100 100 90 093 36 069 90 71 67 97 Wound 0 00 0 00 52 98 8 0 14 0 infection Preterm 0 00 6 43 4 0 00 4 11 4 2 prelabour rupture of membranes Urinary tract 0 00 2 43 0 0 00 1 14 0 infection Endometritis 0 00 2 14 1 0 00 2 48 1 Upper 0 00 1 01 0 10 1 64 0 respiratory tract infection Other/ 0 00 1 01 12 122 2 68 0 Unknown Figures are percentage rounded to the nearest whole number BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Page 5 of 11 (page number not for citation purposes) Table 4: Health outcomes for infants who were born by caesarean section (as percentage of caesarean born babies) Indonesia Malaysia The Thailand Philippines Overall Tertiary District Overall Tertiary 1 Tertiary 2 Overall Tertiary 1 Tertiary 2 Overall Regional University Provincial n = 628 n = 294 n = 334 n = 465 n = 272 n = 193 n = 479 n = 126 n = 353 n = 1074 n = 342 n = 342 n = 390 Stillbirth 1.0 2.0 0.0 0.9 0.4 1.6 0.2 0.8 0.0 0.4 0.0 0.6 0.5 Babies born 0.3 0.0 0.6 0.4 0.4 0.5 0.4 0.8 0.3 1.1 0.9 1.5 1.0 alive who died # Total deaths 1.3 2.0 0.6 1.3 0.7 2.1 0.6 1.6 0.3 1.5 0.9 2.0 1.5 Gestational 38.8 38.3 39.2 37.9 37.8 38.3 37.8 38.1 37.7 38.3 37.9 38.1 38.8 age at birth (2.2) (2.7) (1.4) (2.0) (2.2) (1.7) (2.1) (1.5) (2.2) (2.2) (2.3) (2.3) (2.0) (weeks) * Gestational 10 18 3 13 15 11 10 312 12 16 13 9 age at birth < 37 weeks Birth weight 2.97 2.87 3.01 3.02 3.0 3.05 2.8 2.89 2.76 3.06 3.0 3.1 3.13 (kg) * (0.65) (0.74) (0.56) (0.70) (0.71) (0.69) (0.60) (0.48) (0.63) (0.60) (0.58) (0.63) (0.57) very low birth 3 51 3 33 3 14 2 23 1 weight (< 1500 g) low birth 16 20 13 15 15 15 21 15 24 10 16 8 7 weight (1500–2499 g) normal 77 70 83 74 74 75 75 85 71 84 79 86 87 (2500–4499 g) macrosomia 5 54 8 78 1 01 4 43 5 (≥ 4000 g) Resuscitation 43 40 46 7 510 16 19 15 60 21 57 97 Apgar 35 42 28 8 79 9 810 6 77 4 score < 7 at 1 min Apgar 9 14 5 2 23 3 24 2 22 2 score < 7 at 5 min Figures are percentage rounded to the nearest whole number, or percentagerounded to one decimal point or *mean (standard deviation) Calculated for live births only BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Page 6 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 missing data and thus ensured transcription errors were operatively almost universally, while in the other hospital minimized. 41% of mothers received antibiotics pre-operatively and 43% post-operatively, with the remainder given intra- Data analysis operatively after umbilical cord clamping. In Thailand Data analysis was performed using STATA software Ver- almost 90% of women were given prophylactic antibiotics sion 8.0 [18]. Descriptive analysis was performed between intra-operatively after umbilical cord clamping, with the hospitals within countries as well as across countries. For next most common time of administration being pre- categorical data, frequencies were used to describe mater- operatively. nal characteristics, maternal and perinatal care practices and birth outcomes. For continuous data, means and Cephalosporin was the most common class of prophylac- standard deviations (SDs) were used. tic antibiotics used across all hospitals with a rate of 73%. Ampicillin was the next most commonly used antibiotic Ethics Approval in Malaysia and Thailand, while 'other' antibiotics were The SEA-ORCHID project was approved by the local eth- the next most common in Indonesia and The Philippines. ics committees of each hospital and by the ethics commit- The frequency of dose for prophylactic antibiotics varied tee of the University of Sydney, the administering both between countries and between hospitals in coun- institution in Australia. tries. Mothers in Indonesia received multiple doses of pro- phylactic antibiotics while mothers in Malaysia received Results either a single dose or multiple doses depending on their Of the 9550 women, 2592 (27%) women and their 2645 births or the hospital. In The Philippines and Thailand (27%) babies were born by caesarean. Actual rates varied rates ranged from 1% to 93% for single doses of prophy- from 12% to 39% between hospitals and from 19% to lactic antibiotics and from 7% to 99% for multiple doses. 35% between countries (Table 1). Caesarean section and blood loss (Table 2) Rates and indications for caesarean section (Table 1) In Indonesia, Malaysia, and Thailand, the majority of The most common indications for caesarean were malpre- women were reported to have a less than 500 ml esti- sentation, previous caesarean section, cephalopelvic dis- mated blood loss, while in the Philippines 79% were esti- proportion, and fetal distress. In Indonesia and Malaysia, mated to have a greater than 500 ml blood loss. The the most common indication was malpresentation with reported postpartum haemorrhage rate > 500 ml for Indo- rates of 5.5% and 5.0% respectively. In The Philippines, nesia was only 4%. Malaysia reported the highest rate for caesarean in a previous pregnancy was the most common postpartum maternal transfusion (9%). indication for a caesarean for mothers who gave birth again (10.1%), while cephalopelvic disproportion was the Postnatal care after caesarean section (Table 3) most frequent indication in Thailand (11.4%). Mothers were often given prophylactic antibiotics postna- tally with rates varying between countries and between Common pregnancy complications such as preeclampsia hospitals within countries. All mothers in Indonesia were and antepartum haemorrhage were not often given as given prophylactic antibiotics postnatally. Rates varied indications for caesarean. Although maternal request for a widely between hospitals in Malaysia (3% and 94%), The caesarean was relatively frequent in one of the tertiary Philippines (38% and 98%) and Thailand (15% to 97%). hospitals in Indonesia (3.7%), this was not an indication The main reason for giving antibiotics postnatally to in Malaysia, Thailand and The Philippines. women was prophylaxis and this was commonly prac- ticed in Indonesia (100%), Thailand (90%) and Malaysia Prophylactic antibiotic use for mothers who gave birth by (90%), although it was less common in The Philippines caesarean section (Table 2) (36%) where wound infection was the main reason Prophylactic antibiotics were almost universally given reported (52%) for postnatal antibiotic administration. across all four countries in South East Asia, with only one Birth and infant health outcomes (Table 4) tertiary hospital in The Philippines reporting a slightly lower rate of 91%. There was variation in the timing of The mean gestational age at birth of babies born by cae- prophylactic antibiotics, both between countries and sarean across the hospitals was similar (range 37.7 (SD between hospitals within countries. In Indonesia, prophy- 2.2) to 39.2 (SD 1.4) weeks). The preterm birth rate (< 37 lactic antibiotics were universally given post-operatively. weeks gestation) varied widely from 3% to 18% between In one Malaysian hospital they were always given pre- hospitals although similar from 10% to 13% between operatively, while in the other they were given post-oper- countries. Overall, 16% of the babies born by caesarean atively 95% of the time. In one hospital in The Philip- were of low birth weight (< 2500 g), with rates ranging pines, mothers were given prophylactic antibiotics pre- from 8% to 28% between hospitals. The mean birth Page 7 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 weight of babies ranged from 2.76 kg (SD 0.63) to 3.13 kg fore we consider misclassification unlikely to account for (SD 0.57) between hospitals and 2.8 kg (SD 0.60) to 3.06 variation between institutions. kg (SD 0.60) between countries. Previous caesarean section as an indication for caesarean There were wide variations in the use of neonatal resusci- section is not a recommendation of the NCCWCH/RCOG tation at caesarean. Babies born by caesarean in Thailand UK guidelines [2]. The high incidence of this as an indica- received resuscitation in 60% of cases, however actual tor for caesarean section in the four South East Asian rates varied widely between hospitals, ranging from 21% countries could be due to women or providers choosing in the regional hospital to 97% in the provincial hospital. this option after a previous complicated birth; a scenario In Malaysia, only 7% of babies born by caesarean received more common in developing countries [20]. In addition, resuscitation. Rates of babies with Apgar scores < 7 at 5 women may not be fully informed and educated about minutes were higher in the two Indonesian hospitals vaginal birth and associated pain and management [21]. compared with hospitals in the other three South East High caesarean rates may be attributed to limited knowl- Asian countries (5% and 12% compared with range 1% to edge and training of health professionals in developing 4%). countries causing limited implementation of recommen- dations such as vaginal birth after caesarean (VBAC). It is The rates for caesarean section where the baby was still- known that maternal morbidity particularly increases fol- born ranged between 0% to 1% between countries and lowing elective caesarean section [9] and caesarean sec- 0% to 2% between hospitals within countries. The rates tion without medical indications [10] in developing for babies born alive by caesarean who then died were countries. It is known that VBAC is an option provided the reported as 0% overall for Indonesia, Malaysia and The details of the previous caesarean are available and there is Philippines, with these three countries recording a rate of close monitoring during labour with the ability to pro- 1% in one hospital each, while Thailand recorded a rate of ceed to an emergency caesarean if needed [22,23]. 1% in all hospitals as well as overall. Other NCCWCH/RCOG-recommended indicators for Discussion caesarean section including multiple pregnancy, mother Caesarean section rates in South East Asian countries to child transmission of disease, maternal request, pla- Actual caesarean rates in developing countries, including centa praevia and preterm or small for gestational age [2] South East Asia, are largely unknown because of a lack of were reported as minimal indicators for caesarean section reliable data. Our results showed the overall caesarean in the South East Asian hospitals audited. rates, for all hospitals and all countries in the audit, to be 27%, higher than the WHO recommended rates of Use of antibiotic prophylactic between 5 and 15 percent [7]. This may be attributable to The use of prophylactic antibiotics is recommended to the fact that most of the hospitals audited were referral reduce endometritis and wound infection after elective or centres, meaning a higher proportion of women with non-elective caesarean section [24]. This knowledge has complications from other lower category hospitals would been applied in all hospitals of the four South East Asian have been sent to these hospitals. Some of the variation in countries audited, where prophylactic antibiotics were caesarean section rates between hospitals may be related almost always given. to differing maternal characteristics. Regardless, the cae- sarean rates in the South East Asian countries and hospi- Evidence suggests that prophylactic antibiotics should be tals audited are higher than the nationally representative administered pre-operatively to result in the lowest risk of data available [19]. surgical wound infection [24]. The variation in timing of antibiotic prophylactic administration between hospitals, Main indications for caesarean section and the lack of consistent timing in relation to the type of Women in the four South East Asian countries audited institution may suggest that some individual hospitals were more likely to have a caesarean if they or their infant have developed standardized policies for use of antibiotic experienced malpresentation, previous caesarean section, prophylactics, while some individual health professionals cephalopelvic disproportion or fetal distress. The may practice in line with their own preferences at other National Collaborating Centre for Women's and Chil- hospitals. dren's Health (NCCWCH) with The Royal College of Obstetricians and Gynaecologists (RCOG) [2] guidelines First generation cephalosporin and ampicillin have been list malpresentation, cephalopelvic disproportion and found to be equally effective agents for antibiotic prophy- fetal distress as main indicators for caesarean section, con- laxis for women who underwent a caesarean [25] and this sistent with the indications in our population. Trained recommendation was followed in nearly 90% of all cases staff coded the main reasons for caesarean section, there- reviewed in the four South East Asian countries. Page 8 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Multiple doses of prophylactic antibiotics have been received blood transfusions. Postnatal care for mothers found no more effective than a single dose [25] and are varied widely between hospitals within countries and also more expensive. It is therefore of interest that our review across countries. found that all mothers who underwent caesarean in Indo- nesia, in one hospital in Malaysia and in one hospital in Competing interests Thailand, were given multiple doses. Current evidence The authors declare that they have no competing interests. does not support this expensive practice. Authors' contributions Advantages and limitations of the study MF, DHS and CC contributed to the design of the study. There is lack of completeness of reporting for deaths and ML and PP cleaned and analysed the data and all authors infection within South East Asian hospitals. The reporting contributed to the interpretation of data. ME prepared the may be improved for certain outcomes that may be con- first draft of the paper. All authors commented on each sidered as important quality control or assurance indica- draft of the paper. tors for health care. Many of the SEA-ORCHID data indicators may be recommended for such purpose. The Acknowledgements The SEA-ORCHID study is jointly funded by an International Collaborative health indicators used were clearly defined and dedicated Research Grant from the National Health and Medical Research Council of data staff were trained in their collection. The variation in Australia (No. 307703) and Wellcome Trust, United Kingdom (071672/Z/ care practices seen such as for use of resuscitation of the 03/Z). All authors were funded individually by their respective university/ newborn at caesarean section, are likely to reflect different institution for the preparation of the project proposal. hospital policies as well as differences in casemix. The following persons and institutions participated in the SEA-ORCHID Adherence to best practice recommendations Study Group. Within nine hospitals in four South East Asian countries, Project Investigators: our audit has shown varying and non-structured uptake of evidence-based clinical guidelines and recommendations P. Lumbiganon, MR. Festin, JJ. Ho, M Hakimi, DJ. Henderson-Smart, S. in relation to caesarean section. This may be due to lack of Green and CA. Crowther availability and access to medical journals and reviews and therefore limited dissemination of evidence-based Project Coordinators: guidelines and recommendations. Availability of access and enablers and barriers to uptake of evidence based SJ. McDonald, M. Laopaiboon guidelines need to be examined at individual institutions. Project Administrators: The SEA-ORCHID study plans to conduct a survey of evi- dence-based practice knowledge and clinical change M. Murano, N. Narash among maternal and infant health practitioners in South East Asia to explore this issue [16]. It would be of benefit Data collection and entry at participating hospitals: for each institution to develop policies regarding caesar- ean, and particularly the timing and dosing of administra- INDONESIA tion of prophylactic antibiotics so as to encourage Country Investigator: M. Hakimi standardized practice and to reinforce that access to knowledge and information is important. Dr Sardjito Hospital, Yogyakarta, Indonesia Conclusion Data collection: Supiyah. The baseline rates of caesarean section, associated clinical practices and outcomes varied considerably in nine hospi- Data entry: L. Amanah, D. Lukitasari and D. Astuti tals of four South East Asian countries comprising Thai- Sleman District Hospital, Yogyakarta, Indonesia land, The Philippines, Malaysia and Indonesia. The most common indications for caesarean delivery were malpre- Data collection: L. Amanah sentation, previous caesarean section, cephalopelvic dis- proportion, and fetal distress. Maternal request remained Data entry: L. Amanah, D. Lukitasari and D. Astuti rare. Giving prophylactic antibiotics was nearly universal, MALAYSIA with variations in the timing of administration, (either pre-operatively, after cord clamping, or post-operatively), Country Investigator: JJ. Ho and variation also in the class and number of doses of antibiotics given. Blood loss during caesarean was com- Ipoh Hospital, Perak, Malaysia monly estimated to be less then 500 ml. A few women Page 9 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 Data collection: SS. Cham 3. Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, Velazco A, Shah A, Campodonico L, Bataglia V, Faundes A, Langer A, Narvaez A, Donner A, Romero M, Reynoso S, Simonia de Padua K, Giordano D, Data entry: SS. Cham Kublickas M, Acosta A, for the WHO 2005 global survey on maternal and perinatal health research group: Caesarean delivery rates and Universiti Sains Malaysia, Kota Bharu, Malaysia pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 2006, 367:1819-1829. Data collection: ET. Aw 4. Althabe F, Sosa C, Belizán J, Gibbons L, Jacquerioz F, Bergel E: Cae- sarean section rates and maternal and neonatal mortality in Data entry: SS. Cham low-, medium- and high-income countries: an ecological study. Birth 2006, 33:270-277. THAILAND 5. Stanton C, Holtz S: Levels and trends in caesarean birth in the developing world. Stud Fam Plann 2006, 37:41-48. 6. World Health Organization: Appropriate technology for birth. Country Investigator: P. Lumbiganon Lancet 1985, 2:436-437. 7. World Health Organization: Indicators to monitor maternal Kalasin General Hospital, Kalasin, Thailand health goals. In Report of a Technical Working Group Geneva: WHO; 8. Hofmeyr G, Say L, Gulmezoglu A: WHO systematic review of Data collection: B. Khianman, A. Pharprapa, J. Nachaipet maternal mortality and morbidity: the prevalence of uterine rupture. BJOG 2005, 112:1221-1228. Data entry: N. Narash and R. Poombankor 9. Oladapo O, Lamina M, Sule-Odu A: Maternal morbidity and mor- tality associated with elective caesarean delivery at a univer- sity hospital in Nigeria. Aust N Z J Obst Gynaecol 2007, Khon Kaen Regional Hospital, Khon Kaen, Thailand 47(2):110-114. 10. MacDorman M, Declercq E, Menacker F, Malloy M: Infant and neo- Data collection: B. Saenrien, N. Srisutthikamol, S. Panikom, C. Khunudom, natal mortality for primary caesarean and vaginal births to S. Thipawat, S. Choonhapran, S. Nuanbuddee, P. Jarudphan, A. Hempira women with "no indicated risk". United States, 1998–2001 birth cohorts. Birth 2006, 33:175-182. 11. Ronsmans C, Holtz S, Stanton C: Socioeconomic differentials in Data entry: N. Narash and R. Poombankor caesarean rates in developing countries: a retrospective analysis. Lancet 2006, 368:1516-1523. Srinagarind Khon Kaen Univeristy Hospital, Khon Kaen, Thailand 12. Holtz S, Stanton C: Assessing the quality of caesarean birth data in the Demographic and Health Surveys. Stud Fam Plann Data collection: P. Tharnprisan, P. Sarapon, O. Ponpun 2007, 38:47-54. 13. Huskins WC, Ba-Thike K, Festin MR, Limpongsanurak S, Lumbiganon P, Peedicayil A, Purwar M, Shenoy S, Goldmann DA, Tolosa JE, Global Data entry: N. Narash and R. Poombankor Network for Perinatal and Reproductive Health: An international survey of practice variation in the use of antibiotic prophy- THE PHILIPPINES laxis in cesarean section. Int J Gynaecol Obstet 2001, 73(2):141-5. 14. Gulmezoglu A, Langer A, Piaggio G, Lumbiganon P, Cillar J, Grim- shawd J: Cluster randomised trial of an active, multifaceted Country Investigator: MR. Festin educational intervention based on the WHO Reproductive Health Library to improve obstetric practices. BJOG 2007, Jose Fabella Hospital, Manila, Philippines 114:16-23. 15. Althabe F, Belizán J, Villar J, Alexander S, Bergel E, Ramos S, Romero M, Donner A, Lindmark G, Langer A, Farnot U, Cecatti JG, Carroli G, Data collection: C. Ubaldo-Anzures and LN. Canete Kestler E, Latin American Caesarean Section Study Group: Manda- tory second opinion to reduce rates of unnecessary caesar- Data entry: J. Magsipoc and JL. Festin ean sections in Latin America: a cluster randomised controlled trial. Lancet 2004, 363:1934-1940. Philippines General Hospital (University of the Philippines), Manila, 16. Henderson-Smart DJ, Lumbiganon P, Festin MR, Ho JJ, Mohammad H, McDonald SJ, Green S, Crowther CA, for the SEA-ORCHID Study Philippines Group: Optimising reproductive and child health outcomes by building evidence-based research and practice in South Data collection: E. Torralba and LN. Canete East Asia (SEA-ORCHID): study protocol. BMC Med Res Meth- odol 2007, 7:43. Data entry: J. Magsipoc and JL. Festin 17. The SEA-ORCHID Study Group: Use of Evidence-Based Prac- tices in Pregnancy and Childbirth: South East Asia Optimis- ing Reproductive and Child Health in Developing Countries AUSTRALIA Project. PLoS ONE 2008, 3(7):e2646. 18. StataCorp: Stata Statistical Software: Release 8. College Sta- Country Investigators: D. Henderson-Smart, S. Green, CA. Crowther tion. TX: Stata Corp LP; 2003. 19. Betrán AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, Van Look P, Wagner M: Rates of caesarean section: analysis of global, Project Coordinator: SJ. McDonald. regional and national estimates. Paediatr Perinat Epidemiol 2007, 21:98-113. References 20. Kwawukume EY: Caesarean section in developing countries. 1. Onsrud L, Onsrud M: Increasing use of caesarean section, even Best Pract Res Clin Obstet Gynaecol 2001, 15(1):B165-178. in developing countries. Tidsskr Nor Laegeforen 1996, 21. Tangcharoensathien V, Lertiendumrong J, Hanvaoravongchai A, Ben- 116(1):67-71. nett S: Caesarean deliveries in Thailand: cause for concern. 2. National Collaborating Centre for Women's and Children's Health: Regional Health Forum, WHO South-East Asia Region 2007, 6(2): [http:/ Caesarean section: Clinical Guideline. London: RCOG Press; /www.searo.who.int/EN/Section1243/Section1310/Section1343/ 2004. Section1344/Section1356_5321.htm]. Page 10 of 11 (page number not for citation purposes) BMC Pregnancy and Childbirth 2009, 9:17 http://www.biomedcentral.com/1471-2393/9/17 22. Royal College of Obstetricians and Gynaecologists (RCOG): Birth after previous caesarean birth. 2007 [http://www.rcog.org.uk/ womens-health/clinical-guidance/birth-after-previous- caesarean- birth-green-top-45]. UK: Guidelines and Audit Committee RCOG 23. American College of Obstetricians and Gynecologists (ACOG): Vag- inal birth after previous caesarean delivery. 2004 [http:www.guideline.gov/summary/sum mary.aspx?doc_id=6374&nbr=4043&ss=15]. Washington (DC): American College of Obstetricians and Gynecologists (ACOG) 24. Smaill F, Hofmeyr G: Antibiotic prophylaxis for caesarean sec- tion. Cochrane Database Syst Rev 2002:CD000933. 25. Hopkins L, Smaill F: Antibiotic prophylaxis regimens and drugs for caesarean section. Cochrane Database Syst Rev 1999:CD001136. Pre-publication history The pre-publication history for this paper can be accessed here: http://www.biomedcentral.com/1471-2393/9/17/prepub Publish with Bio Med Central and every scientist can read your work free of charge "BioMed Central will be the most significant development for disseminating the results of biomedical researc h in our lifetime." 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