Association between delayed cesarean section and severe maternal and adverse newborn outcomes in the Somaliland context: a cohort study in a national referral hospital

ABSTRACT

Background

In a critical obstetric situation, the time interval between the decision of performing a caesarean section (CS) and delivery can influence maternal and newborn outcomes. In Somaliland, consent for surgical procedures, such as CS needs to be sought from family members.

Objective

To determine the association between a delay in performing a CS and severe maternal and newborn outcomes in a national referral hospital in Somaliland. The type of barriers leading to delayed performance of CS after a doctor’s decision were also explored.

Methods

Women were followed from the time of decision to perform CS until discharge from the hospital between 15 April 2019 and 30 March 2020. No delay was defined as < 1 hour and delayed CS was defined as 1–3 hours and >3 hours from decision of CS to delivery. Information was collected on barriers leading to delayed CS and maternal and newborn outcomes. Data was analysed using binary and multivariate logistic regression.

Results

Overall, 1255 women were recruited from a larger cohort of 6658 women. A delay in CS >3 hours was associated with higher odds of severe maternal outcomes (aOR 1.58, 95% CI [1.13–2.21]). On the contrary, delay in performing a CS >3 hours was associated with lower odds of stillbirth (aOR 0.48, 95% CI [0.32–0.71]) compared to women without delay. Further, family decision-making for consent was the most important barrier leading to delays of >3 hours as compared to financial factors and barriers related to healthcare providers (48% vs 26% and 15%, respectively, p < 0.001).

Conclusions

In this setting, delay in performing CS >3 hours was associated with higher risk of severe maternal outcomes. A standardised system of performing a CS by primarily addressing the barriers associated with family decision-making, financial aspects and healthcare providers is needed.

KEYWORDS:

• Delayed caesarean section
• severe maternal outcomes
• adverse newborn outcomes
• barriers
• Somaliland

Responsible Editor Stig Wall

Responsible Editor Stig Wall

Acknowledgements

We would like to thank the staff in the obstetrics department of Hargeisa Group Hospital.

Author contributions

All the authors (JK, FO, JE, MK, HL) participated in the conceptualisation of the study design. JE and JK were responsible for training the data collectors, and supervising data collection. JK conducted the initial data analysis and writing of the manuscript. All authors contributed to the data analysis and interpretation of the results and reviewed the manuscript. All authors participated sufficiently in the study to take public responsibility for appropriate portions of the content.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Ethics and consent

Permission to conduct the study was obtained from the Somaliland Ministry of Health Development (MoHD). Ethical clearance was provided by the research ethics committee of the University of Hargeisa (Dr: CS/41105/18).

Paper context

As compared to previous research on CS delay and various obstetric diagnoses, this study analysed the association of CS delay with life-threatening conditions defined as severe maternal outcomes according to the sub-Saharan African near-miss criteria. We found that prolonged CS delay >3 hours contributed to SMOs. Our study adds new knowledge with regard to how delayed CS due to contextual factors, such as healthcare providers, financial factors, or family decision-making leading to delayed CS contribute to SMOs in Somaliland.

Additional information

Funding

This study was supported by Dalarna University, Institution of Health and Welfare and Uppsala University, Department of Women’s and Children’s Health.