MODE OF DELIVERY, ADVERSE NEONATAL OUTCOMES, AND WOMEN'S BIRTH EXPERIENCE: A PROSPECTIVE FOLLOW UP STUDY AT PUBLIC HOSPITALS INEASTERN ETHIOPIA

Abstract

Background: Nearly 2.4 million neonatal deaths occur worldwide during the first 28 days of life, primarily due to infections, preterm birth complications, and intrapartum complications. In Ethiopia, 80,000 newborn deaths are recorded per year due to preventable neonatal health problems. Access to cesarean birth is one strategy to reduce this mortality. However, according to the world health organization, a cesarean section rate exceeding 15% is not associated with lower maternal and neonatal mortality. Instead, it is associated with adverse neonatal outcomes such as respiratory distress, low Apgar score, and intensive care unit admission. It also affects women's birth experiences. This study tried to investigate adverse neonatal outcomes and the women's birth experience based on the mode of delivery. It also identified the commonest indications and determinants of cesarean section and predictors for vaginal birth after cesarean section. Methods: A hospital-based follow-up study was conducted in Hiwot Fana Specialized University Hospital and Jugal Hospital in Harar, Bisidimo hospital in Eastern Hararghe, Oromiya, and DilChora Hospital in Dire Dawa from June to October 2020. A total of 2,246 women with labor experience visited the hospitals were followed up during the delivery and postpartum until discharged from the hospital to document the women's experience and neonates' outcomes. Data were collected by face-to-face interview using a structured pre-tested questionnaire. A phenomenological approach study design was used to explore women's birth experiences. Data were collected using an in-depth interview with a semi-structured interview guide which considered four domains of the Roy adaptation theory (physiological, self-concept, role and function, and interdependence). Multinomial logistic regression was used to identify determinants of the cesarean section. In addition, logistic regression and modified poison regression were employed to assess predictors of the successful vaginal birth after cesarean section and adverse neonatal outcome, respectively. Results: From 2,246 eligible participants, 1,525 (67.9%, 95%CI 64-.0-68.2) had a vaginal delivery, and the rest 721(32.10, 95%CI:30.0, 34.0) delivered through cesarean section; with 25.4% of them delivered by emergency cesarean section. Neonates born via CS were more likely to have adverse neonatal outcomes (AOR 1.41 95% CI; 1.09, 1.83), and rural residency increased the likelihood of an adverse outcome (AOR 2 1.53 95% CI; 1.16, 2.16). Partograph follow-up reduced the likelihood of the adverse outcome (AOR 0.67, 95% CI; 0.51, 0.84). The risk was significantly higher among babies with low birth weight and delayed initiation of respiration and born through both delivery modes. The odds of experiencing an emergency cesarean section were 2.2 times more among women who had a history of stillbirth (AOR: 2.22;95% CI:1.26,3.92). Women with antenatal follow-up decreased emergency cesarean section by 68% (AOR: 0.32;95% CI: 0.25, 0.43). Antenatal and partograph follow-up increased the chance of successful vaginal birth after cesarean section. According to qualitative findings, women who gave birth via cesarean section had less physiologic adaption due to surgical site pain and anesthesia. Similarly, anxiety about the surgical procedure, concerns about future pregnancies, and prolonged hospital stay led to poor adaptation to self-concept mode among cesareans section groups compared to women who gave birth through vaginal birth. Moreover, they were less adaptive to role and function and interdependence mode due to inability to care for themselves and their babies and lack of family support. Conclusion: Low birth weight, delay initiation of respiration, meconium stain amniotic fluid, and parity were predictors for adverse outcomes. The common indication for emergency cesarean section was obstructed labor, whereas previous cesarean section was the leading cause of elective cesarean section. Nearly one-third of the women who had previous cesarean sections were not allowed to try a vaginal birth. Antenatal care and partograph follow-up were the modifiable predictors that increased the success of vaginal birth after cesarean section. Therefore, it is critical to focus on antenatal care follow-up and partograph to monitor women during labor to reduce the cesarean section rate. Besides, the qualitative study indicated that the women who gave through cesarean section had less adaptation to Roy's model. Various interventions are needed to raise awareness and change current practices by involving health professionals and women to reduce unnecessary cesarean sections associated with poor neonatal outcomes and a negative birth experienc