Neonatal survival following cesarean delivery in northern Cameroon

The United Nations recommends a population-based cesarean delivery rate of between 5% and 15% of the estimated number of expected live births [1]. Several studies in low-resource countries have found a positive correlation between country-specific cesarean delivery rates and a reduction in maternal mortality, stillbirth, and neonatal mortality rates. The national cesarean delivery rates for most countries in sub-Saharan Africa are around 2%, and this figure was reported for Cameroon in 2004 [2]. Stillbirth rates of between 7% and 12% have been reported at the University Hospital in Yaoundé, Cameroon, and the facility-based cesarean delivery rate ranges between 9% and 18% [3]. However, little is known about the neonatal outcomes of cesarean deliveries performed in the Far North Province of Cameroon, where the cesarean delivery rate of 0.4% is reportedly the lowest in the country.

The aim of the study was to evaluate the neonatal outcomes of cesarean deliveries performed in the Provincial Hospital in Maroua, the capital of the Far North Province. Data were collected retrospectively from delivery and operating room registers between January 1 2003 and December 31 2004. A total of 144 cesarean deliveries were performed during the study period, and 125 were eligible for inclusion. After identification of each eligible cesarean delivery, data from the following 2 consecutive vaginal deliveries were collected to give a comparison group of 244 vaginal deliveries.

Data were analyzed using SPSS (SPSS, Chicago, IL, USA), and tests, risk ratios, and 95% confidence intervals were used to compare neonatal outcomes. The significance level was set at 0.05.

Of the 3263 deliveries over the study period, 144 (4.4%) were by cesarean and the indications are shown in Table 1. Compared with women who delivered vaginally, women who had a cesarean delivery were more likely to have had fewer than 4 prenatal visits (23.2% vs 31.6%), and more likely to be younger than 17 years (6% vs 12%) and grand multiparous (13% vs 25%). There were more cases of low APGAR score (defined as equal to or less than 6) in the neonates delivered by cesarean compared with vaginal delivery (17.6% vs 4.1%; hazard ratio [HR] 8.2, 95% CI, 3.6–18.4; P<0.001). After adjusting for potential confounders such as maternal age, parity, number of prenatal visits, neonatal birth weight, and neonatal sex, the cases of low APGAR score remained significantly greater in the cesarean delivery group (HR 8.2, 95% CI, 3.4–19.3; P<0.001) (Table 2). Similarly, the stillbirth rate was greater in the cesarean delivery group compared with the vaginal delivery group (29.6% vs 4.1%; HR 13.0, 95% 5.8–29.1; P<0.001) (Table 2).

Table 1. Indications for cesarean deliveries performed over the study period a

	Indication	Cesarean deliveries (n=144)
	Absolute indications	97 (67.4)
	Cephalopelvic disproportion	47 (32.6)
	Placenta previa	13 (9.0)
	Cord prolapsed	10 (6.9)
	Uterine rupture	9 (6.3)
	Arm prolapsed	7 (4.9)
	Malpresentation	7 (4.9)
	Fibroid previa	2 (1.4)
	Placental abruption	2 (1.4)
	Relative indications	28 (19.4)
	Multiple pregnancy	10 (6.9)
	Failure to progress	6 (4.1)
	Hypertensive disorders	4 (2.8)
	Scarred uterus	3 (2.1)
	Malformation	3 (2.1)
	Fetal distress	2 (1.4)
	Undefined	19 (13.2)

a Values are given as number (percentage).

Table 2. Neonatal APGAR score and stillbirth rates according to mode of delivery

	Neonatal outcome	No. (%)	Crude risk (hazard ratio)a (95% CI)	Adjusted risk (hazard ratio) b (95% CI)
	Low APGAR score (≤6)
	Vaginal delivery (n=244)	10 (4.1)	1c	1c
	Cesarean delivery (n=125)	22 (17.6)	8.2 (3.6–18.4)d	8.2 (3.4–19.3)d
	Stillbirth
	Vaginal delivery (n=244)	10 (4.1)	1c	1c
	Cesarean delivery (n=125)	37 (29.6)	13.0 (5.8–29.1)d	10.6 (4.6–24.4)d

a Adjusted for maternal age. b Adjusted for maternal age, parity, prenatal care, neonatal weight, and neonatal sex. c Referral category. d P<0.001.

There were 3 maternal deaths among the 144 cesarean deliveries, giving a maternal mortality rate of 2.1%. The stillbirth rates according to birth weight were 30%, 7%, 11%, and 31% among the neonates weighing 1000–2000 g, 2000–2499 g, 2500–3999 g, and over 4000 g, respectively.

The cesarean delivery rate of 4.4% in the present study is lower than the lowest rate of 9% reported for the University Teaching Hospital in Yaoundé [3], and lower than the threshold rate of 5% recommended by the United Nations. We had anticipated a greater number of cesarean deliveries because the Provincial Hospital is the referral hospital for the whole province and provides 69% of cesarean deliveries in the health district. Most surrounding maternity units only conduct vaginal deliveries. Therefore, we believe that the true population-based cesarean delivery rate is likely to be lower than the 4.4% reported in this study.

Cephalopelvic disproportion was the most common indication for cesarean delivery in our series (32.6%). In the USA, dystocia is the most common indication (68%) for cesarean delivery [4].

The stillbirth rate is reported to range between 7% and 14% for countries in sub-Saharan Africa. Some grand multiparous women may consider themselves experienced at delivering and try for a home birth and then arrive late at the hospital after complications have presented. Macrosomy could be identified during pregnancy if women were able to access good prenatal care. These conditions contribute to the well known “3 delays” (delay in seeking care, delay in reaching a health care facility, and delay receiving attention at the facility) and cesarean deliveries are often performed when the degree of asphyxia is already too advanced. In addition, women have to pay for the supplies needed to perform a cesarean before the operation begins and there is often no equipment available.

Health workers must be trained to provide effective and continuous prenatal care centered on the patient. Retraining in emergency obstetric care is required and equipment to perform cesarean deliveries must be available.