INTRODUCTION
Caesarean
section (CS) is an incision on the pregnant uterus to deliver a baby via the
abdominal route, at the age of fetal viability. [1] Its a life
saving operative procedure usually employed when delivery by the vaginal
route is judged unsafe. [1, 2]
Caesarean section is one of the most common
surgical procedures in obstetrics, and various rates have been reported. Analysis
of a pool of data on CS from 154 countries, covering 94.5% of world live births
(from 2010 – 2018) revealed an overall CS rate of 21.1%. [3] In the UK, reported
rates were 34.5% in Scotland, 31% in England, and 28% in Wales. [4] A systematic
review and meta-analysis in Nigeria involving 45 articles, reported an overall
prevalence of 17.6%. [5] At Ngora district in Eastern
Uganda, a rate of 14% was reported. [6]
As a result of increased awareness and
acceptance, coupled with the increasing rate of litigations, the CS rate has
been on the increase. In the US, the rate was reported to increase by 60%; from
20.7% in 1996 to 32.1% in 2021. [7] A study has published the rise in CS rates
according to sub-regions globally (from 2010 to 2018). The highest was in Eastern Asia (44.9%), followed by Western Asia (34.7%),
and Northern Africa (31.5%). [3] The sub-regions with the least rise were
Northern America 9.5% and Sub-Saharan Africa 3.6%. [3]
Aversion
to caesarean section may explain why Sub-Saharan
Africa had the least rise over the years. This may be attributed to
traditional, cultural and religious beliefs, and safety concerns. A study in
Nigeria reported an aversion rate of 20.9%. [8] Another study in Nigeria (at Federal
Teaching Hospital Abakaliki) reported that 20.3% of
pregnant women refused CS for no reason, [9] and the major barriers to
accepting CS were stigma of not being able to deliver vaginally, cultural beliefs,
and high cost. [9] Another study at Agbor in Delta
State, Nigeria, reported the acceptance rate as 54%. [10]
The
indications for caesarean section in Sub-Saharan Africa seem to follow a
similar trend. In Eritrea, the 6 most common indications in Dekemhare
Hospital were malposition (26.3%), prolonged and obstructed labour
(21.2%), mal-presentation (14.4%), repeat cesarean section (10.2%), amniotic
fluid disorders (9.3%), and fetal distress (5.9%). [11] A similar study at Ngora district in Uganda reported that the major
indications were obstructed labour 17.9%, fetal
distress 15.3%, big baby 11.6%, and cephalopelvic
disproportion (CPD) 11%. [6] In Nigeria, at University of Abuja Teaching
Hospital, CPD (30.8%) was the most common indication, followed by fetal
distress (23.6%) and severe pre‑eclampsia/eclampsia
(10.9%). [12]
Evidence
from hospital based studies in Nigeria indicates that a great majority of
caesarean sections were done as emergencies. Some reported rates were: 93.7% at University of Nigeria Teaching
Hospital, [13] 80.2% at
University of Abuja Teaching Hospital, [12] and 83.28% in Calabar. [14]
Maternal
complications from CS are quite common and primary postpartum hemorrhage (PPH)
seems to predominate in Nigeria. A study at University of Calabar
Teaching Hospital reported PPH as the most common complication in 12.3% of the
cases. [14] A collaborative study involving two tertiary institutions at Abakaliki in Ebonyi State,
implicated PPH (44.2%) as the most common complication, followed by wound sepsis
(12.3%). [15] Other complications commonly encountered are postpartum anemia,
soft tissue injuries (like bladder or bowel injury), and anesthetic complications.
[1, 2]
Fetal
complications are also quite common, a study at King Abdulaziz Medical City, Jeddah in Saudi Arabia reported low
APGAR score (prenatal asphyxia) and intensive care
unit (ICU) admission as the most common complications of CS. [16] A systematic review and meta-analysis in
Iran reported transient tachypnea as the most common fetal complication.
[I7] At Ayder Specialized Comprehensive
Hospital, Tigray in Ethiopia, the most common
complications were low birth weight (17.2%), stillbirth (2.6%), and early
neonatal death (2.4%). [18]
We found it necessary to take an indebt look
into our caesarean sections in NDUTH over the past 6 years, to critically
evaluate: our prevalence, indications, and the outcome, with special emphasis
on maternal and fetal complications, and vital statistics. Our findings may be
of paramount importance to the women; it has the potential to change the
dynamics of our management plans, protocols and decisions.
OBJECTIVES
The
main objective of this study is to audit the pattern, trend and outcome of
caesarean section at NDUTH over the past 6 years.
Specifically, it would determine: the
socio-demographic characteristics of the patients, the caesarean section rates,
the indications, and the associated obstetrics features such as booking status,
and the type of caesarean section.
It would also determine the maternal
complications, fetal and maternal vital statistics, and the factors associated
with poor fetal outcome.
METHODOLOGY
Study site
The study was
carried out at the department of obstetrics and gynaecology,
Niger Delta University Teaching Hospital, Yenagoa, Nigeria.
Subjects
Pregnant women
(both booked and unbooked) who were delivered by
emergency caesarean section.
Study design
A retrospective cross-sectional study of 599
pregnant women delivered by caesarean section at NDUTH. The study was carried
out from January 2017 to December 2022.
Inclusion criteria
Included in
this study were pregnant women delivered by caesarean section at NDUTH during
the study period. These include women who registered for antenatal care in
NDUTH, those referred from other health institutions for CS, and those that
came on self referral.
Exclusion criteria
Excluded from this study were women who were
admitted in labour, and had spontaneous or
instrumental vaginal delivery.
Data collection:
Data
was collected at the antenatal clinic, antenatal ward, labour
ward, labour ward theatre, and the neonatal care
unit. Information retrieved include: bio-data, booking status, indication for
caesarean section, gestational age at delivery, and the type of caesarean
section (elective or emergency). Others were: duration of hospital stay, and
maternal complications, including mortalities related to caesarean section.
Information retrieved on the fetus were:
birth weight, APGAR score (at 5 minutes) for birth
asphyxia, fetal status (alive or dead), type of the fetal demise (macerated or
fresh still birth), and the factors associated with poor fetal outcome.
The criteria for poor
fetal outcome
For
the purpose of this study, poor fetal outcome was based on the following
criteria:
1.
Moderate
birth asphyxia (APGAR score of 4 – 6)
2.
Severe
birth asphyxia (APGAR score of 0 – 3)
3.
Fetal
demise - APGAR score of 0, if there is
no sign of life after resuscitation by the pediatrician for a period of 20
minutes
4.
Admission
into neonatal care unit (immediately after birth).
5.
Fetal
macrosomia (birth weight of ≥ 4.5kg)
6.
Prematurity
babies delivered < 34 weeks gestation, or low birth weight (birth weight
< 2500 grams).
Data analysis
Data
collected from each subject was entered into SPSS version 25 spread sheath, and
EPI info version 7 software, and analyzed. Results were presented in tables as
rates, proportions, and mean, with standard deviation. Test of significance was
by odds ratio, and chi square (χ2). Confidence interval was
set at 95%, and statistical significance was set a p values ≤ 0.05.
Ethical Approval
Ethical
approval for this study was granted by the NDUTH ethical committee, with registration
number NDUTH/REC/0032/2024
RESULTS
The 5
most significant factors associated with poor fetal outcome were: unbooked status (p = 0.0001), fetal distress (p = 0.001),
prolonged obstructed labour, p = 0.001), low educational
status (p = 0.02), CS done as emergency p = 0.03.
Other significant factors are: unemployment p
= 0.04, abruptio placenta p = 0.04, and poor progress
in labour p = 0.04.
DISCUSSION
Among
the procedures in medical practice, caesarean section is distinct, as it saves
the lives of both mother and fetus. Without this procedure, the cost to
humanity (the maternal and fetal morbidity and mortality) would have been
tremendous.
As stated earlier, a
study ranked Sub-Saharan Africa as the sub-region (globally) with the least
rise in CS rate over the years. [3] In our
study, out prevalence increased marginally (by just 2%) over the past 6 years,
which is in agreement with the above findings, and also at par with the 1.1%.
reported at Ebonyi
State in Nigeria. [15]
Very
low CS rates have been reported in centers across Nigeria; 3.11% from analysis
of 2018 Nigeria National demographic Survey, [19] and 2.1% from another study
in Nigeria. [20] A similar study in Nigeria got a rate of 1.0% for low risk
pregnancies, and 7.1% for high risk. [21] and an
overall rate of 17.6% was obtained
from a mata-analysis in Nigeria. [22]
The
low CS rate in West Africa may be attributed to multiple factors such as:
safety concerns, cultural and religious beliefs, high illiteracy rate, and aversion
to CS. [8. 23] A study in Port Harcourt in Nigeria identified the reasons for
aversion as: stigma of not being able to deliver vaginally (52.7%), high cost
(63.7%), and the risk of dying from the procedure (51.0%). [24] Another study
in Abakaliki reported that 20% of women rejected CS
because of stigma of not being able to deliver naturally (29.22%), high cost of
CS (20.8%), and religious beliefs (12.5%). [9]
In addition, many caesareans sections in
Nigeria are done in private clinics,
especially in rural settings, where records may not be properly incorporated
into the national health records. This as a matter of fact has the potential to
negatively affect the CS indices in the country.
In West Africa
(including Nigeria), there is a very high tendency for our pregnant women to
deliver outside the hospital setting, especially with traditional birth
attendants (TBA), and this could reduce our CS rates. A study reported that in rural parts of Africa, 60% to 90% of pregnant women deliver with TBA.
[25] Poverty and the high cost of CS are believed to be strong catalysts that
rapidly propagate this practice.
Wrong financial perception about CS is another factor; a
study in Nigeria reported that in hospitals, 25% of doctors recommend caesarean
section for their financial advantage, but not for medical reasons. [24]
On
literature search, the CS rate of 31% we got from our study was the third
highest in Nigeria; 35.5% at Oshobo, [26] and 41.4%
in Port Harcourt. [27] However, much lower
results were obtained in other centers. A systemic review and
meta-analysis on CS involving 45 articles, reported an overall prevalence of
17.6% in Nigeria. [22] Other reported rates are: 7.22% in Enugu, [28] 23.2% at Abakaliki, [15], 25.6% in Calabar,
[14] and 21.4% in Abuja. [12] The reason for the high rate we got in NDUTH is
not very clear, but it may be due to our low utilization of alternative mode of
delivery, like obstetric forceps.
Among
the indications for CS globally, some are more peculiar to poor resource setting,
like Sub-Saharan Africa. Prolonged obstructed labour,
eclampsia, and severe preeclampsia or imminent eclampsia are examples, [6, 11, 12]
and they featured prominently in the top 5 indications in our study. These are
absolute indications for CS, and often due to complications from mismanaged labour or antenatal care.
The
high rate of the absolute indications stated above, plus cephalopelvic
disproportion might have contributed immensely to our high rate of emergency CS
of 82.6%. However, NDUTH is not in isolation, and the problem seems to cut
across various regions in Nigeria. A very high rate of 93.7% was obtained in
Enugu [13], in Calabar
it was 83.3%, [14] and 80.2%.
in Abuja. [12]
Experience
from our obstetrics units indicates that the patients with the above
complications are predominantly unbooked, and managed
in labour for several hours, (and even days) before
they are referred to hospital. Undue delay often results in life threatening
complications like: fulminant sepsis, eclampsia,
obstructed labour, and ruptured uterus. While some
present with fetal distress, and intra-uterine fetal death. The usual culprits
in Nigeria are TBA, health centers and private clinics. Unfortunately, we have
not done a study to objectively access the impact of late patients’ referral
for CS in our facility, and this is a wake-up call.
Excessive
bleeding during caesarean section (PPH) is about the commonest maternal
complication during CS, and it has been reported in various studies in West
Africa. A study in Ethiopia identified PPH as a very common complication of CS,
with an incidence of severe PPH of 4.6%. [29] In Nigeria, PPH was reported as
the commonest maternal complication in Calabar
(12.3%), [14] and 44.2% at Abakaliki in Ebonyi State. [15]
PPH
as a dominant complication of caesarean in Nigeria was clearly demonstrated in
this study, as PPH was the most common complication in NDUTH. However, our rate
of 8.5% was lower than the results from some other centers in Nigeria, as
stated above. The low rate was most probable because our resident doctors were
trained to be very careful during surgery, and to strictly follow the existing
CS protocols. As a rule in NDUTH, a senior colleague is always on standby (in
theatre) waiting to intervene when complications arise. Among the top 5
complications of CS we observed in our study were postpartum anemia, puerperal
Sepsis, and wound dehiscence.
Puerperal sepsis and
wound breakdown (dehiscence) are very common in Nigeria, especially among the unbooked patients. As earlier stated, most of these patient
were badly managed (in labour) by TBA and health centers,
and they often present with sepsis secondary to prolonged rupture of fetal
membranes. Some have actually ruptured membranes for several days, prior to
presentation. A study in Enugu reported that 79.4% of term pregnancies had prolonged
rupture of fetal membranes, [30] and the rate of chorioamnionitis
was 16.2% (using clinical indicators of infection), and 50% using histological
diagnosis. [30]
It’s
therefore not surprising that our rate of puerperal sepsis, and wound infection
was high (among the top 5 complications) in this study, because of our high
rate of prolonged rupture of membranes (18.4%), and un-booked patients (44.6%).
Similar high rates of wound sepsis have been reported in other centers in
Nigeria; 25% in Kano [31] and 16.0% in Ekiti [32]
Though
we acknowledge the fact that under no circumstance should a woman die in labour or from labour
complications, it’s almost impossible to achieve this gold standard in
developing countries, like Nigeria. There are too many bottle-neck obstacles,
and the issues are complex. They include: lack of health facilities (especially
in rural areas), lack of political will, poor implementation of health
policies, high level of illiteracy, poverty, and the influence of religion, and
socio-cultural practices.
However,
we had only 3 maternal deaths (from CS complication) during the study period,
with a maternal mortality ratio of 482.3/100,000 live births. This did not deviate
widely from other centers in Southern Nigeria; 646/100000 in Calabar, [14] and the 139/1000 in Enugu. [33] However a Multicentre study conducted predominantly in Northern
Nigeria (about 80% of the data was from Kano and Kaduna) had a very high ratio
of 1,315/100,000. [34] This is
because in Nigeria, the mortality indices are worse in some parts of Northern
Nigeria. [35] South Africa, (though an African country) is more developed than
Nigeria, and their mortality records are better, 3.2 deaths per 10 000. [36]
Regarding
fetal complications, birth asphyxia was the most common complication we got
from our study, and it seems to be the most common fetal complication in many
centers in Nigeria. A study in Enugu reported that more than half (57.7%) of
the babies delivered by CS had birth asphyxia, [12] at Asaba,
the rate was 27.6%. [37] From our
study, birth asphyxia was the most common cause of perinatal mortality in
babies delivered by CS in NDUTH.
With
respect to perinatal mortality from CS, our perinatal mortality rate of
128.6/1000 births is at par with findings from Abakaliki,
Ebonyi State in Southern Nigerian (134.7/1,000 births), [15] but lower than what was reported
in Jigawa State in Northern Nigeria (165.6 per 1000 births). [38]
CONCLUSION
Our CS rate is quite
high, and this is largely attributed to too many emergencies. Though our
maternal mortality ratio and perinatal mortality rate are comparable to those
from other centers in Nigeria, they are too high going by international
standards. There is no justification for our pregnant women to die during
childbirth or lose her babies. Advocacy to encourage our women to register for
antenatal care, women empowerment, and early referral (of women with labour complications) to hospital would improve our
morbidity and mortality indices.
Conflict of Interest: The authors have
declared there was no conflict of interest.
Acknowledgement: The authors wishes
to acknowledge the Head of Department of Obstetrics and Gynaecology
NDUTH.
REFERENCES
1.
Sung S, Mahdy H. Cesarean Section.
In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024: https://www.ncbi.nlm.nih.gov/books/NBK546707/
PMID: 31536313.
2.
Sulochana D-R, Edwin V. T, Pramod R. R, Juliet W, Ganesh D, Keshar
B. D. A brief history and indications for cesarean section. Journal of Patan
Academy of Health Sciences. 2021; 8(3): 101-11.
doi.org/10.3126/jpahs.v8i3.27657
3.
Betran A. P, Ye J, Moller A, et al.
Trends and projections of caesarean section rates: global and regional
estimates. BMJ Global Health 2021; 6: e005671
4.
Scottish
Government. The Best Start - caesarean section rates: review report. Directorate of Children and Families, Health
and Social Welfare. 2021: ISBN 9781802012644
5.
Osayande, I.,
Ogunyemi, O., Gwacham-Anisiobi,
U. et al. Prevalence, indications, and complications of
caesarean section in health facilities across Nigeria: a systematic review and
meta-analysis. Reprod Health.
2023; 20, 81: doi.org/10.1186/s12978-023-01598-9
6.
Isaac
W, Sandra N, Winnie N, Isaac N, Margret
O, Jacob I, et al. Prevalence, Indications, and Community Perceptions of
Caesarean Section Delivery in Ngora District, Eastern
Uganda: Mixed Method Study. Hindawi Obstetrics and
Gynecology International. 2020; 1-11: https://doi.org/10.1155/2020/5036260
7.
Stephenson
J. Rate of First-time Cesarean Deliveries on the Rise in the US. JAMA Health Forum. 2022;
3(7): e222824. doi:10.1001/jamahealthforum.2022.2824
8.
Aboyeji P. A,
Adegboyega
A. F, Olayinka R. B, Kikelomo T. A, Salamat Isiaka-Lawal.
Evaluation of parturient perception and aversion before and after primary
surgery caesarean delivery in a low resource country. International Journal of Obstetrics and Gynaecology.
2016; 132: 77 – 81.
9.
Lucky
O. L, Francis N. I, Chukwuemeka I. U,
Okechukwu B. A, Chukwuemeka
A. I, Fidelis A. O, Tagbo A. A. Perception and
Socio-cultural Barriers to the Acceptance of Caesarean Delivery in A Tertiary
Hospital in Abakaliki, South East Nigeria. International Journal of Women’s Health and
Reproduction Sciences. 2019; 7(2): 163–8
10.
Maduka R. N, Enaruna N. O. Acceptance of repeat cesarean section and its
determinants among a Nigerian pregnant women population. Sahel Med J. 2021; 2 (4): 104-10.
11.
Idris M, Menghisteab,
Selam. Cesarean section delivery rates,
determinants, and indications: a retrospective study in Dekemhare
Hospital. . Global Reproductive Health. 2022; 7(1): DOI: 10.1097/GRH.0000000000000056
12.
Isah A. D, Adewole
N, Zaman J. A five-year survey of cesarean delivery
at a Nigerian tertiary hospital. Trop J Obstet Gynaecol 2018; 35: 14-7
13.
Ugwu EO, Obioha KC, Okezie OA, Ugwu AO. A five-year survey of caesarean delivery at a
Nigerian tertiary hospital. Ann Med
Health Sci Res. 2011; 1(1): 77-83. PMID: 23209958
14.
Njoku C. O, Emechebe
C. I, Edet E. E, Oyama S.
E, Iklaki C. U. The Trend, Determinants And Maternal Outcome of Caesarean Section At The
University of Calabar Teaching Hospital, Calabar, Nigeria; A 5 Year Appraisal. IOSR
Journal of Dental and Medical Sciences (IOSR-JDMS). 2016: 15(12): 75-9. DOI: 10.9790/0853-15120107579
15.
Robinson C. O, Justus
N. E, Paul O. E, Lucky O. L, Chukwuemeka A. I, Peter
O. N. A 10-year appraisal of cesarean delivery and the associated fetal and
maternal outcomes at a teaching hospital in southeast Nigeria. International Journal of Women’s Health.
2015: 7: 531–8
16.
Aljohani AA,
Al-Jifree HM, Jamjoom RH, Albalawi RS, Alosaimi AM. Common
Complications of Cesarean Section during the Year 2017 in King Abdulaziz Medical City, Jeddah, Saudi Arabia. Cureus. 2021; 13(1): e12840. doi: 10.7759/cureus.12840.
17.
Rafiei M, Saei Ghare M, Akbari
M, Kiani F, Sayehmiri F, Sayehmiri K, Vafaee R.
Prevalence, causes, and complications of cesarean delivery in Iran: A
systematic review and meta-analysis. Int J Reprod Biomed. 2018; 16(4): 221-34. PMID: 29942930.
18.
Mengesha M. B, Adhanu
H. H, Weldegeorges D. A, Assefa
N. E, Werid W. M, et
al TT. Maternal and fetal outcomes of cesarean delivery and factors
associated with its unfavorable management outcomes; in Ayder
Specialized Comprehensive Hospital, Mekelle, Tigray, Ethiopia, 2017. BMC
Res Notes. 2019; 12(1): 650. doi:
10.1186/s13104-019-4690-5.
19.
Ajayi K. V, Olowolaju
S, Wada Y. H, Panjwani S, Ahinkorah
B, Seidu A-A, et al.
A multi-level analysis of prevalence and factors associated with
caesarean section in Nigeria. PLOS Glob
Public Health. 2023; 3(6): doi.org/10.1371/journal.pgph.0000688
20.
Adewuyi E. O, Auta A, Khanal V, et al Cesarean delivery in Nigeria:
prevalence and associated factors―a population-based cross-sectional
study BMJ Open 2019; 9: e027273. doi: 10.1136/bmjopen-2018-027273
21.
Berglundh S, Benova L, Olisaekee G, Hanson C.
Caesarean section rate in Nigeria between 2013 and 2018 by obstetric risk and
socio-economic status. Trop Med Int Health. 2021; 26(7): 775-88. doi: 10.1111/tmi.13579.
22.
Itohan O, Olakunmi O, Uchenna
G‑A, Abimbola O, Sanni
Y, Aduragbemi B. T.
Prevalence, indications, and complications of caesarean section in health facilities across Nigeria: a systematic review and meta-analysis. Reproductive Health. 2023; 20: 81. doi.org/10.1186/s12978-023-01598-9
23.
Adewuyi E. O,
Auta A, Khanal V, Tapshak S. J, Zhao Y. Cesarean delivery in Nigeria:
prevalence and associated factors-a population-based cross-sectional study. BMJ Open. 2019; 9(6): doi: 10.1136/bmjopen-2018-027273
24.
Ordinioha B, Ugboma H, A.
Caesarean section: the perspectives of women in Port Harcourt, Nigeria. Port
Harcourt Medical Journal. 2009; 4(2): Doi10.4314/phmedj.v4i2.52525
25.
Okonofua F, Ogu R.
Traditional versus birth attendants in provision of maternity care: call for
paradigm shift. Afr J Reprod Health.
2014; 18(1): 11–2.
26.
Daniel Adebode Adekanle, Adewale Samson Adeyemi, Adeniyi Olanipekun Fasanu. Caesarean section at a tertiary institution in Southwestern Nigeria—a
6-year audit. Open Journal of Obstetrics
and Gynecology, 2013;3: 357-61. doi.org/10.4236/ojog.2013.33066
27.
Felix Chikaike Clement Wekere,
Rose Sitonma Iwo-Amah, Joseph Ngozi Kwosah , Adetomi Bademosi, Simeon Chijioke Amadi. A Five-Year
Review of Caesarean Section at the Rivers State University Teaching Hospital,
South-South, Nigeria. Journal of Advances in Medicine and Medical Research. 2021; 33(23): 159-67.
28.
Gunn
J. K. L, Ehiri J. E, Jacobs E. T, Ernst K. C, Pettygrove S, Center K. E, et al. Prevalence of Caesarean sections in Enugu,
southeast Nigeria: Analysis of data from the Healthy Beginning Initiative. PLoS ONE. 2017; 12(3): e0174369.
doi.org/10.1371/journal.pone.0174369
29.
Negese K, Belachew D. Z. Maternal complications and associated
factors among mothers who underwent a cesarean section at Gebretsadik
Shewa general hospital: an institution based
cross-sectional study. Front Glob Womens Health. 2023; 4: 1091863. doi: 10.3389/fgwh.2023.1091863.
30.
Asogwa A. O, Ezugwu
E. C, Eleje G. U, Chidinma
O. I, Asogwa . FK, Ezugwu O. C, et al.
Association of clinical signs of chorioamnionitis
with histological chorioamnionitis and neonatal
outcomes in women with premature rupture of membranes. Niger J Clin Pract.
2023; 26: 1354 - 60
31.
Jido T, Garba I.
Surgical-site Infection Following Cesarean Section in Kano, Nigeria. Ann Med Health Sci
Res. 2012; 2(1): 33- 6. doi:
10.4103/2141-9248.96934
32.
Taiwo O. Dayo-Dada, Adeleke A. Ojo, Oluwaseyi A. Akpor, Prevalence of surgical site infection among
caesarean section patients in a teaching hospital in Ekiti
State, Nigeria: An eight-year review. Scientific
African. 2022: e01216, ISSN 2468-2276.
33.
Ezugwu E. C, Iyoke C. A, Iloghalu
I. E, Ugwu E. O, Okeke T. C,
Ekwuazi K. E. Cesarean section rate and its outcome in a
tertiary hospital in Enugu, South-east Nigeria. Int. J. Med. Health Dev. 2017; 22(1): 24 - 30.
34.
Galadanci H, Dongarwar D, Künzel W, Shittu O, Yusuf M, Abdurrahman S, Lufadeju
D, Salihu H. M. Cesarean Section and Maternal-fetal
Mortality Rates in Nigeria: An Ecological Lens into the Last Decade. Int J MCH AIDS. 2020; 9(1): 128 - 35. doi: 10.21106/ijma.349.
35.
Ope B. W. Reducing
maternal mortality in Nigeria: addressing maternal health services’ perception
and experience. Journal of Global Health Reports. 2020; 4: e2020028. doi:10.29392/001c.12733
36.
Salome
Maswime, Eckhart Buchmann , Eckhart Buchmann. Causes and avoidable factors in maternal
death due to cesarean-related hemorrhage in South Africa. International Journal of Gynecology and Obstetrics. 2016; 134: 320 –
323
37.
Jombo S, Ossai C, Onwusulu D, Ilikannu S, Fagbemi A. Feto-maternal outcomes of caesarean delivery in Federal
Medical Centre, Asaba: a two year review. Afr Health Sci. 2022; 22(1): 172-9. doi: 10.4314/ahs.v22i1.22.
38.
Ugwa E, Ashimi A, Abubakar M. Y.
Caesarean section and perinatal outcomes in a sub-urban tertiary hospital in
North-West Nigeria. Niger Med J.
2015; 56(3): 180 - 4. doi:
10.4103/0300-1652.160360.
