Prevalence, indications, and outcomes of caesarean section deliveries in Ethiopia: a systematic review and meta-analysis

Background Caesarean section rates have increased worldwide in recent decades. Caesarean section is an essential maternal healthcare service. However, it has both maternal and neonatal adverse outcomes. Therefore this systematic review and meta-analysis aimed to estimate the prevalence, indication, and outcomes of caesarean section in Ethiopia. Methods Twenty three cross-sectional studies with a total population of 36,705 were included. Online databases (PubMed/Medline, Hinari, Web of Science, and Google Scholar) and online university repository was used. All the included papers were extracted and appraised using the standard extraction sheet format and Joanna Briggs Institute respectively. The pooled prevalence of the caesarean section, indications, and outcomes was calculated using the random-effect model. Result The overall pooled prevalence of Caesarean section was 29.55% (95% CI: 25.46–33.65). Caesarean section is associated with both maternal and neonatal complications. Cephalopelvic disproportion [18.13%(95%CI: 12.72–23.53] was the most common indication of Caesarean section followed by non-reassuring fetal heart rate pattern [19.57% (95%CI: 16.06–23.08]. The common neonatal complications following Caesarean section included low APGAR score, perinatal asphyxia, neonatal sepsis, meconium aspiration syndrome, early neonatal death, stillbirth, and prematurity whereas febrile morbidity, surgical site infection, maternal mortality, severe anemia, and postpartum hemorrhage were the most common maternal complications following Caesarean section. Conclusion In this systematic review and meta-analysis, the rate of Cesarean section was high. Cephalopelvic disproportion, low Apgar score, and febrile morbidity were the most common indication of Caesarean section, neonatal outcome and maternal morbidity following Caesarean section respectively. Increasing unjustified Caesarean section deliveries as a way to increase different neonatal and maternal complications, then several interventions needed to target both the education of professionals and the public.


Background
Caesarean section is the commonest operative delivery technique in the world. Caesarean section is the delivery of the fetus, membrane, and placenta through abdominal and uterine incision after fetal viability [1].
The rate of Caesarean section is different across countries even between urban and rural areas, due to different socio-economic statuses, and opportunities to access public and private health care services [2].
According to American College of Obstetricians and Gynecologist (ACOG) report, Caesarean delivery significantly increased woman's risk vulnerability of pregnancyrelated morbidity and mortality which accounts (35.9 deaths per 100,000 live deliveries) as compared to a women posses vaginal delivery (9.2 deaths per 100,000 live births) [3].
Despite Caesarean section a life saving medical intervention and procedures to the decrease adverse birth outcome, controlling different postoperative neonatal and maternal complications are challenging in terms of patient safety, long duration of hospital stay, cost and psychological trauma. Maternal outcomes of Caesarean section included: postpartum fever, surgical site infection, puerperal sepsis, maternal mortality whereas neonatal sepsis, early neonatal death, stillbirth, perinatal asphyxia, low Apgar score, and prematurity were the most common complication of the newborn [4][5][6].
Despite World Health Organization (WHO) recommended the optimal rate of Caesarean section should be lie between 5 and 15%, it is significantly increasing even if the reasons for the continued increase in the Caesarean rates are not completely understood: women are having fewer children, maternal age is rising, use of electronic fetal monitoring is widespread, malpresentation especially breech presentation, frequency of forceps and vacuum delivery is decreased, rate of labor induction increases, obesity dramatically rises and Vaginal birth after Caesarean decreased are some of the possible explanations [7].
According to the 2016 Ethiopia Demographic and Health Survey, the rate of C-section (21.4%) in Addis Ababa was far more than the 10-15% rate recommended by the world health organization. EDHS (2016) report showed there is an absolute difference rate of Caesarean section across different regions in Ethiopia which accounts Amhara (2.3%), Oromia (0.9%), SNNPR(1.9%), Afar (0.7%), Tigray (2%), Somali(0.4%), Benishangul Gumuz (1%) too far from the lowest 5% WHO recommendation of Caesarean section deliveries. This review helps to see C-section rates beyond 15% and below 5% is considered medically unjustified or unnecessary, with negligible benefits for most mothers, and yet costly and unequally distributed throughout the population [9,10].
Ethiopia is a good case study to assess Caesarean prevalence, indications, and outcomes because, like other countries in sub-Saharan Africa, maternal mortality and neonatal mortality did not decline sufficiently to meet the Sustainable Development Goal for maternal health and child, and was estimated at 412 maternal deaths and 29 neonatal deaths per 100,000 live births in 2016 [9].
Despite a few single studies stated different maternal and fetal outcomes of Caesarean section, there is a lack of data to show the distribution and outcome of Caesarean section in different regions where they are provided.
This systematic review and meta-analysis aimed to estimate the pooled prevalence of Caesarean section deliveries and to determine the indications and outcomes of Caesarean section deliveries in Ethiopia.

Methods
This systematic review and meta-analysis have been conducted to estimate the pooled prevalence of Caesarean section, indications, maternal and neonatal outcomes in Ethiopia via the standard PRISMA checklist guideline.

Inclusion and exclusion criteria
Twenty three (23) cross-sectional studies were included. Articles reported prevalence or/and an indication, or/ and neonatal outcomes or/and maternal outcomes were incorporated. Only English language literature and research articles were included. Studies published till October 2019 were reviewed, screened and appraised for this study. Whereas, articles without full abstracts or texts and articles reported out of the scope of the outcome interest were excluded.

Quality assessment
GG, AD & AW independently evaluated the quality of each study using the Joanna Briggs Institute (JBI) quality appraisal checklist [11]. Any disagreement was resolved by the hindrance of the third reviewer (FW, BA &AG). The following JBI items used to appraise cross-sectional studies were: [1] inclusion criteria, [2] description of study subject and setting, [3] valid and reliable measurement of exposure, [7] objective and standard criteria used, [9] identification of confounder, [10] strategies to handle confounder, [12] outcome measurement, and [13] appropriate statistical analysis. Hence, studies considered with the JBI checklist value of 50% and above of the quality assessment indicators as low risk and good to be included for the analysis.

Data extraction
All the datasets are exported to Endnote version X8 software, and then we transferred to the Microsoft Excel spreadsheet to remove duplicate data in the review. Three authors (GG, AD, and AG) independently extracted all the important data using a standardized JBI data extraction format. Any disagreement between reviewers was resolved by the second team reviewers (FW, BA & AW). The consensus was declared through critical discussion and evaluation of the articles by the independent group reviewers. The name of the author, sample size, publication year, study area, response rate, region, study design, the prevalence of specific maternal outcomes, the prevalence of neonatal outcomes, indications of Caesarean section, and prevalence of Caesarean section with 95%CI were extracted. Outcome of measurements Neonatal outcomes Any neonatal outcomes reported following C-section (Stillbirth, prematurity, neonatal sepsis, perinatal asphyxia, low Apgar score, and early neonatal death) were included.

Maternal outcomes
Any maternal complications identified after C-section were included puerperal sepsis, wound infection (surgical site infection), febrile morbidity (puerperal fever), postpartum hemorrhage, severe anemia, and maternal mortality.

Data analysis
A Funnel plot and Eggers regression test was used to check publication bias [14]. Cochrane Q-test and Isquared statistics were computed to check the heterogeneity of studies [15,16]. Pooled analysis was conducted using a weighted inverse variance randomeffects model [17]. Subgroup analysis was done by study region (area), and sample size. STATA version 11 statistical software was used to compute the analysis. Forest plot format was used to present the pooled point prevalence, indications and outcomes of C-section with 95%Cl.

Characteristics of the included studies
Four hundred twenty-three studies were retrieved at PubMed, Google Scholar, Science Direct, web of science, HINARI and other gray and online repository accessed articles regarding prevalence, indications, and the maternal and fetal outcome of Caesarean section in Ethiopia. After duplicates were expunged, 278 studies remained.
Out of 278 remained articles, 176 articles were excluded after review of their titles and abstracts. Therefore, 102 full-text articles were accessed and assessed for inclusion criteria, which resulted in the further exclusion of 79 articles primarily due to reason. As a result, 23 studies were met the inclusion criteria to undergo the final systematic review and meta-analysis ( Fig. 1) (Table 1).

Prevalence of caesarean section in Ethiopia
The overall pooled prevalence of Caesarean section is presented with a forest plot (Fig. 2). Therefore, the pooled estimated prevalence of Caesarean section in Ethiopia was 29.55% (95% CI; 25.46-33.65; I2 = 98.7%, P < 0.001).

Publication bias
A funnel plot was assessed for the asymmetry distribution of the Caesarean section using visual inspection of the forest plot (Fig. 3). Egger's regression test showed with a p-value of 0.251 indicated the absence of publication bias.

Subgroup analysis
Subgroup analysis was computed with the evidence of heterogeneity. Hence the Cochrane I 2 statistic =98.7%, P < 0.001) showed the presence of marked heterogeneity in this study. Therefore subgroup analysis was implemented using the study area (region) and sample size using random model effect analysis. Regarding the study area (region), the prevalence of Caesarean section was highest in Addis Ababa, accounted for 40.39% (95%CI: 12.35, 68.43) whereas the rate of Caesarean section was higher among studies of having sample size less than 500, accounted for 34.91% (95%CI: 25.48-44.34) (Fig. 4-5).

Indication of caesarean section
In this systematic review and meta-analysis; obstructed labor, cephalopelvic disproportion, multiple pregnancies, non-reassuring fetal heart rate pattern (NRFHRP), failed induction and augmentation, malpresentation and malposition, and antepartum hemorrhage are the most common indications of Caesarean section. In this systematic review and meta-analysis, cephalopelvic disproportion (CPD) is the most common indication of Caesarean section followed by non-reassuring fetal heart rate pattern (NRFHRP), and obstructed labor in Ethiopia ( Table 2).

Neonatal complication following caesarean section in Ethiopia
Among women who underwent Caesarean section; neonatal sepsis, early neonatal death, stillbirth, low Apgar score, perinatal asphyxia (PNA), meconium aspiration syndrome, and prematurity were the reported neonatal complications in this study. Among neonatal complications, low Apgar score was the most common adverse complication of the newborn followed by perinatal asphyxia and neonatal sepsis respectively in Ethiopia (Table 3).

Maternal complications following caesarean section in Ethiopia
Following Caesarean section different adverse maternal complications were reported. Febrile morbidity, puerperal sepsis, postpartum hemorrhage, surgical site infection, maternal mortality, and severe anemia were the most common adverse maternal complications following Caesarean section. Puerperal fever or febrile morbidity was the leading cause of maternal morbidity following Caesarean section followed by postpartum hemorrhage in Ethiopia (Table 4).

Discussion
Despite Caesarean section is an essential component of comprehensive obstetric and newborn care for reducing maternal and neonatal mortality, there is a lack of data regarding Caesarean section rates, its indications and outcomes in Ethiopia. Studies showed negative or no complications of Caesarean on neonatal mortality in low and middle-income countries where the Caesarean rates are high. Cesarean section is very crucial in settings where the Caesarean rates are very low, due to the unavailability of Caesarean [39].  Caesarean sections can cause significant and sometimes permanent complications, disability or death particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery and treat surgical complications [40].
Low-and middle-income countries, wealthy women have more than five times higher C-section use than poor women. In the United States, 32% of births were by C-section in 2015, an increase from 23% in 2000, as the data showed, and in the United Kingdom, 26.2% of births were by C-section in 2015, up from 19.7% in 2000. According to the World Health Organization report, the country with the lowest C-section rate, at 0.6% in 2010, was South Sudan and the country with the highest, at 58.1% in 2014, was the Dominican Republic. Whereas, some countries where more than half of births were by C-section were Brazil, at 55.5% in 2015; Egypt, at 55.5% in 2014; Turkey, at 53.1% in 2015; and Venezuela, at 52.4% in 2013 [41].
The overall prevalence of Caesarean section in Ethiopia was 29.55% (95% CI: 25.46-33.65). This report is higher than the study done in Saudi Arabia [42], Nigeria [43], Pakistan [44], India [5], Brazil [45] and low and middleincome countries analysis [46]. This discrepancy might be due to the age of the mother elapses the ideal birth time, significantly increasing, non-communicable disease, increasing electronic fetal monitoring availability and accessibility in referral and general hospitals. This study finding is lower than the study done in Nepal, North America and Western Europe, Latin America and the Caribbean [47]. This difference might be due to countries with a rich wealth index that may have the capacity to have modern operative obstetrics management as compared to low and middle countries. Hence, low and middle-income countries have resource limitation and c-section is resourceconstrained, may have low comprehensive obstetric health care services.
Neonatal sepsis, stillbirth, prematurity, perinatal asphyxia, low Apgar score, and meconium aspiration syndrome were the most common neonatal complications following the Caesarean section in Ethiopia. This study finding is supported by the study done in India [5], Jordan [4], and Ghana [6].
Postpartum hemorrhage, surgical site infection, puerperal fever, anemia, and maternal mortality were the most common neonatal adverse outcome of Caesarean section in Ethiopia. The finding of this study is supported by the study done in India [5], Jordan [4], and African countries [48].

Conclusion
In this study, the overall pooled prevalence of Caesarean section in Ethiopia was high. Non-reassuring fetal heart rate patterns, cephalopelvic disproportion, and obstructed labor were the most common indication of Caesarean section. Low Apgar score, perinatal asphyxia,  and neonatal sepsis were the most common complication of neonates whereas postpartum hemorrhage and febrile morbidity were the common maternal complications following the Caesarean section in Ethiopia. Therefore, based on the study findings, the authors recommend a particular emphasis to follow the WHO recommendations and guidelines. Avoiding unjustified and unnecessary indications for Caesarean sections has a significantly higher impact to prevent poor maternal and fetal outcomes.