/. biosoc. Sci (1992) 24, 515-525
PREVALENCE AND DETERMINANTS OF CAESAREAN SECTION IN JAMAICA LINDA A. WEBSTER*, JANET R. DALINGf, CARMEN McFARLANE|, DEANNA ASHLEY§ AND CHARLES W. WARREN^ *Information Resources Management Office, Centers for Disease Control, Atlanta, ^Department of Epidemiology, University of Washington, Seattle, \McFarlane Consultants, Kingston, Jamaica, ^Ministry of Health, Kingston, Jamaica, and ^Division of Reproductive Health, Centers for Disease Control, Atlanta, Georgia, USA Summary. The prevalence and determinants of primary caesarean section in Jamaica were estimated from a survey of women aged 14—49 years. Among 2328 women reporting 2395 live hospital births during the period January 1984 to May 1989, the prevalence of caesarean section was 4 1 % . Repeat caesarean sections accounted for 1-3% of the hospital births during that period. Of the medical complications studied, prolonged labour and/or cephalopelvic disproportion carried the highest risks of primary caesarean section, followed by breech presentation, maternal diabetes, a high birth-weight baby, maternal hypertension, and a low birth-weight baby. The risk of primary caesarean section increased with maternal age, decreased with parity, was higher for urban than for rural residents, and was higher for births in private versus government hospitals. Introduction
Little information is available on the use of caesarean section in developing countries, but surprisingly high rates have been reported for a small number of developing countries, including 27% for the Mexico City metropolitan area, 29% for Puerto Rico, and 32% in Brazil (Notzon, Placek & Taffel, 1987; Notzon, 1990). These high caesarean section rates raise questions about the delivery of medical care in developing countries, i.e. for whom and why are these sections performed? High caesarean section rates are of considerable public health concern in both developed and developing countries because of the associated higher mortality, morbidity and cost relative to vaginal deliveries. And because medical resources are generally scarce in developing countries, high caesarean delivery rates could place a serious burden on their health care systems. On the other hand, extremely low caesarean section rates have been reported in areas of Africa * Present address: Division of Sexually Transmitted Diseases and HIV Prevention, Centers for Disease Control, Atlanta, Georgia. 515
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(Nordberg, 1984; VandenBroek, VanLerberghe & Pangu, 1989), suggesting that unnecessary obstetrical disasters might occur because of problems with access to medical facilities and a lack of availability of this surgical procedure. This study was undertaken to extend knowledge of the prevalence and reasons for caesarean section in developing countries, with specific reference to Jamaica. Methods The caesarean section study was an area probability survey of Jamaican women aged 14—49 years who gave birth to a live infant during the period January 1984 to May 1989. The study was part of a Contraceptive Prevalence Survey (CPS) funded by the United States Agency for International Development and conducted under the authority of the National Family Planning Board of Jamaica. Technical assistance for the CPS was provided by the Division of Reproductive Health of the Centers for Disease Control (McFarlane & Warren, 1989). Field work for the study began on 28 February 1989 and ended on 11 June 1989. The sample design for the CPS was a two-stage sample where the first stage was based on a geographic frame (enumeration districts) and the second on a frame of dwellings within those selected enumeration districts. Within each of the fourteen parishes on the island of Jamaica, enumeration districts were arranged into a total of 217 sampling regions and, from each region, two enumeration districts were selected for the sample. A list of all dwellings in each of the selected enumeration districts was compiled by staff at the Statistical Institute of Jamaica. Sixteen dwellings were selected from each district, except in seven areas where over-sampling was needed to produce parish-, urban-, and rural-level estimates for the CPS. (The seven areas included the parishes of St James, St Thomas, Portland, St Mary, Trelawny, and Hanover, and the rural areas of St Andrew parish). In these areas, 24 dwellings were selected from each district. This resulted in a total of 8069 dwellings selected for the entire sample. The number of occupied dwellings was 7394 (91-6%). Once an occupied dwelling was selected for the sample, an interviewer (1) enumerated the number of households within that dwelling, (2) completed a household questionnaire that listed the age and gender of all persons who usually lived there, and (3) attempted to interview each 14-49-year-old woman identified in the household listing. There were 7420 households enumerated for 7394 occupied dwellings selected for the sample. Completed interviews were obtained for 7063 households (95-2%). Approximately 2-8% of the households could not be contacted while 1 -9% refused to provide any information. A total of 6694 eligible women were identified for the CPS from the household listings. Interviews were completed for 6330 women (94-6%). Reasons for non-interview included refusals (2-2%) and respondents not at home (1-2%). Approximately 20% of the women gave only partially completed interviews. There were 2328 women who reported a total of 3077 live births since January 1984. Approximately 2395 (77-8%) of these births were hospital deliveries and were included in this analysis.
Caesarean section in Jamaica
517
Personal interviews were conducted with all consenting participants in their homes. The individual questionnaire covered: (1) demographic characteristics of the respondent; (2) marital status; (3) detailed reproductive history for those women who had had a live birth since January 1984; (4) contraceptive history; (5) attitude and knowledge questions regarding AIDS; and, (6) behavioural risk factor information relating to diabetes, hypertension, smoking, and alcoholic beverage consumption. For each live birth reported, the respondent was asked how the baby was delivered, where the delivery occurred, who assisted with the delivery, the birth weight of the baby, and whether any of the following conditions were present at the time of delivery: (1) diabetes or sugar; (2) high blood pressure; (3) baby in breech position; (4) labour lasted more than 1 day, or baby too big, or passage too small (referred to in the analysis as prolonged labour and/or cephalopelvic disproportion); (5) more than one baby (multiple birth); and (6) previous caesarean section. Because seven areas in Jamaica were oversampled for the CPS, sampling weights were calculated and used in all analyses. The weights were determined by adjusting the age distribution of the CPS respondents in each parish to match population estimates based on 1987 official vital statistics data. Prevalence estimates and confidence intervals appropriately adjusted for the study design were calculated (Shah, 1981). To estimate the risk of primary caesarean section, the analysis was restricted to singleton hospital births at risk, i.e. primary or first-time caesarean sections and either normal vaginal or vaginal forceps deliveries with no reported history of caesarean section. A total of 2280 births met these criteria. A logistic regression package developed for survey data was used to model the risk of primary caesarean section (Shah et al., 1987). The following variables were included in the model: maternal age (
PREVALENCE AND DETERMINANTS OF CAESAREAN SECTION IN JAMAICA LINDA A. WEBSTER*, JANET R. DALINGf, CARMEN McFARLANE|, DEANNA ASHLEY§ AND CHARLES W. WARREN^ *Information Resources Management Office, Centers for Disease Control, Atlanta, ^Department of Epidemiology, University of Washington, Seattle, \McFarlane Consultants, Kingston, Jamaica, ^Ministry of Health, Kingston, Jamaica, and ^Division of Reproductive Health, Centers for Disease Control, Atlanta, Georgia, USA Summary. The prevalence and determinants of primary caesarean section in Jamaica were estimated from a survey of women aged 14—49 years. Among 2328 women reporting 2395 live hospital births during the period January 1984 to May 1989, the prevalence of caesarean section was 4 1 % . Repeat caesarean sections accounted for 1-3% of the hospital births during that period. Of the medical complications studied, prolonged labour and/or cephalopelvic disproportion carried the highest risks of primary caesarean section, followed by breech presentation, maternal diabetes, a high birth-weight baby, maternal hypertension, and a low birth-weight baby. The risk of primary caesarean section increased with maternal age, decreased with parity, was higher for urban than for rural residents, and was higher for births in private versus government hospitals. Introduction
Little information is available on the use of caesarean section in developing countries, but surprisingly high rates have been reported for a small number of developing countries, including 27% for the Mexico City metropolitan area, 29% for Puerto Rico, and 32% in Brazil (Notzon, Placek & Taffel, 1987; Notzon, 1990). These high caesarean section rates raise questions about the delivery of medical care in developing countries, i.e. for whom and why are these sections performed? High caesarean section rates are of considerable public health concern in both developed and developing countries because of the associated higher mortality, morbidity and cost relative to vaginal deliveries. And because medical resources are generally scarce in developing countries, high caesarean delivery rates could place a serious burden on their health care systems. On the other hand, extremely low caesarean section rates have been reported in areas of Africa * Present address: Division of Sexually Transmitted Diseases and HIV Prevention, Centers for Disease Control, Atlanta, Georgia. 515
516
L. A. Webster et al.
(Nordberg, 1984; VandenBroek, VanLerberghe & Pangu, 1989), suggesting that unnecessary obstetrical disasters might occur because of problems with access to medical facilities and a lack of availability of this surgical procedure. This study was undertaken to extend knowledge of the prevalence and reasons for caesarean section in developing countries, with specific reference to Jamaica. Methods The caesarean section study was an area probability survey of Jamaican women aged 14—49 years who gave birth to a live infant during the period January 1984 to May 1989. The study was part of a Contraceptive Prevalence Survey (CPS) funded by the United States Agency for International Development and conducted under the authority of the National Family Planning Board of Jamaica. Technical assistance for the CPS was provided by the Division of Reproductive Health of the Centers for Disease Control (McFarlane & Warren, 1989). Field work for the study began on 28 February 1989 and ended on 11 June 1989. The sample design for the CPS was a two-stage sample where the first stage was based on a geographic frame (enumeration districts) and the second on a frame of dwellings within those selected enumeration districts. Within each of the fourteen parishes on the island of Jamaica, enumeration districts were arranged into a total of 217 sampling regions and, from each region, two enumeration districts were selected for the sample. A list of all dwellings in each of the selected enumeration districts was compiled by staff at the Statistical Institute of Jamaica. Sixteen dwellings were selected from each district, except in seven areas where over-sampling was needed to produce parish-, urban-, and rural-level estimates for the CPS. (The seven areas included the parishes of St James, St Thomas, Portland, St Mary, Trelawny, and Hanover, and the rural areas of St Andrew parish). In these areas, 24 dwellings were selected from each district. This resulted in a total of 8069 dwellings selected for the entire sample. The number of occupied dwellings was 7394 (91-6%). Once an occupied dwelling was selected for the sample, an interviewer (1) enumerated the number of households within that dwelling, (2) completed a household questionnaire that listed the age and gender of all persons who usually lived there, and (3) attempted to interview each 14-49-year-old woman identified in the household listing. There were 7420 households enumerated for 7394 occupied dwellings selected for the sample. Completed interviews were obtained for 7063 households (95-2%). Approximately 2-8% of the households could not be contacted while 1 -9% refused to provide any information. A total of 6694 eligible women were identified for the CPS from the household listings. Interviews were completed for 6330 women (94-6%). Reasons for non-interview included refusals (2-2%) and respondents not at home (1-2%). Approximately 20% of the women gave only partially completed interviews. There were 2328 women who reported a total of 3077 live births since January 1984. Approximately 2395 (77-8%) of these births were hospital deliveries and were included in this analysis.
Caesarean section in Jamaica
517
Personal interviews were conducted with all consenting participants in their homes. The individual questionnaire covered: (1) demographic characteristics of the respondent; (2) marital status; (3) detailed reproductive history for those women who had had a live birth since January 1984; (4) contraceptive history; (5) attitude and knowledge questions regarding AIDS; and, (6) behavioural risk factor information relating to diabetes, hypertension, smoking, and alcoholic beverage consumption. For each live birth reported, the respondent was asked how the baby was delivered, where the delivery occurred, who assisted with the delivery, the birth weight of the baby, and whether any of the following conditions were present at the time of delivery: (1) diabetes or sugar; (2) high blood pressure; (3) baby in breech position; (4) labour lasted more than 1 day, or baby too big, or passage too small (referred to in the analysis as prolonged labour and/or cephalopelvic disproportion); (5) more than one baby (multiple birth); and (6) previous caesarean section. Because seven areas in Jamaica were oversampled for the CPS, sampling weights were calculated and used in all analyses. The weights were determined by adjusting the age distribution of the CPS respondents in each parish to match population estimates based on 1987 official vital statistics data. Prevalence estimates and confidence intervals appropriately adjusted for the study design were calculated (Shah, 1981). To estimate the risk of primary caesarean section, the analysis was restricted to singleton hospital births at risk, i.e. primary or first-time caesarean sections and either normal vaginal or vaginal forceps deliveries with no reported history of caesarean section. A total of 2280 births met these criteria. A logistic regression package developed for survey data was used to model the risk of primary caesarean section (Shah et al., 1987). The following variables were included in the model: maternal age (
