Frequency of Caesarean Section and its Indications in A Tertiary Care Teaching Hospital

Day by day increasing Cesarean section rate is the major concern in obstetricians’ community There is need to establish local guidelines and Cesarean section should be performed according to specific indications mentioned in guidelines.1 WHO recommended Cesarean Section rate 10 – 15%.2 This is far away from actual rate in current practice. In Pakistan actual rate of Cesarean section is difficult to calculate as most of the low risk deliveries take place at home while only complicated cases reach hospital.3 The high rate of caesarean sections in developed countries is because of fetal distress and in developing countries the most common cause is not yet clear.4  Non availability of one to one care and resources like continuous CTG monitoring, availability of whole obstetrical emergency team including anaesthetist and neonatologist to carry operative procedure within 15 min, lack of policies for giving trial to previous scared uterus and cesarean section on maternal wish are other causes of increasing rate.3 This increase in rate of Caesarean Section is also increasing the maternal morbidity in terms of repeated Caesarean section, adhesions, increase blood loss and morbidly adherent placenta.1 High rate of caesarean section is an alarming concern for public health globally both for  government and  family  as it causes high financial burden. In order to decrease all the above mentioned concerns only absolute indications of cesarean sections should be considered like Cephalopelvic disproportion (CPD), placenta previa, and malpresentation.3

Aim of this study is to find out caesarean section indications their demographic and obstetrical determinant in order to find out strategies for reduction of causative factors of maternal and neonatal morbidity and mortality like prolonged stay at health care facility, blood transfusion, anemia, morbidly adherent placenta and caesarean hysterectomies due to morbidly adherent placenta

Design of this study was descriptive cross sectional study. It was conducted at Rai Foundation Teaching Hospital Sargodha in the department of obstetrics and gynaecology from 01-01-2025 to 31-12-2025. Sample was taken with convenience sampling technique. All Pregnant ladies coming in the study period in antenatal clinic or admitted from emergency for delivery were incorporated in the study. The patients with ruptured uterus were omitted. The questionnaire was filled regarding age, parity, gestational age, type of Cesarean Section, its indication, previous scar condition, blood loss and fetal outcome. Data was analyzed on SPSS 25 for frequency and percentages. P-value ≤ 0.05 was considered statistically significant

Table 1: Distribution of Socio-demographic factors

During one year study period, total 913 patients were delivered. Among them 193 patients were delivered through caesarean sections and 720 were delivered vaginally. The percentage of caesarean section was 21.1%. Sociodemographic details are given in Table I.

Among 193 patients 137 (70.9%) were between 21 to 30 years of age, 38(19.6%) were between 31 to 40 years of age and 18(9.3%) were < 20 years of age. Most of the patients whose Caesarean section were performed belongs to rural area 167(86.5%). Elective caesarean section was performed in 140 (72. 5%) patients and emergency caesarean section in 53 (27.5%).

A statistically significant difference was found in the distribution of C-section types between rural and urban residents (p < 0.05). This indicates that the residential status plays a role in determining the likelihood of undergoing elective or emergency C-sections. Further exploration into the underlying socio-demographic and healthcare access disparities between rural and urban areas is warranted to elucidate this association.

It was observed that intraoperatively condition of previous caesarean section scar was better in elective caesarean section as compared to emergency caesarean section (p value < 0.01). This showed the importance of considering the history of cesarean scar in the decision-making process for subsequent pregnancies. It was also noted that NICU admissions were more common in emergency caesarean section than elective. (p < 0.01). This was reflecting the urgency and complexity associated with neonatal care in these cases.

Table II shows the indications of Caesarean section.

Previous caesarean section was the commonest indication seen in 115 (59.6%) patients (p value 0.043).  Second common indication was IUGR with Oligohydramnios 30(15.5%) with p value 0.046. Followed by fetal distress 15(17.8%).  Malpresentation was the cause of Caesarean section in 10(5.2%)

During one year of  study period caesarean section frequency of was 21.14%, higher in contrast  to WHO recommended rates (10-15%)5, which is consistent with the study conducted in lady reading Hospital  Peshawar  in 20151. In contrast the rate of Caesarean section in the maternity teaching hospital in Erbil city Kurdistan Iraq is 35.77%.Which is much higher because it is the main maternity hospital in Erbil and most of the deliveries (NVD and CS) are referred to that hospital6.

According to the systemic reviews and meta-analysis of caesarean section rates and indications in Turkey, the total caesarean section rate is 43% and primary caesarean section rate is 26%. The rate was 21% in 2002 and in 2018 it increased to 54.9% pushing turkey up to the highest position in this class among the countries of OECD (Organization for economic cooperative & development)7

Again some studies have reported caesarean rates of 31% in Thailand, 41% in Ecuador, 31% in the US and 36% in china.8, 9, 10, 11

The rising trend in Turkey due to the increase in malpractice suits the convenience offered to mothers and obstetrician at private hospitals the pressure placed on the doctors by the performance system that has been adopted resulting in the reduction in midwife led births the medicalization of childbirth. Changes in women perception and fears of normal childbirth and the misconception that caesarean birth is safe for the baby. 12, 13

Systemic reviews have showed that the increase in caesarean section rates beyond 10-15 % at the population level are no longer associated with reduced maternal or neonatal mortality rates as surgical risks outweigh benefits. 14, 15

In our study the commonest indication is previous caesarean section that is 59.6% which is supported by another study the national review conducted between 2015 -2019 in Bhutan showed commonest indication for caesarean section is previous caesarean section (27.5%)16

203 studies were meta analyzed the results showed that planned repeat caesarean section had much increased maternal mortality compared with planned vaginal birth after caesarean section (VBAC) (1.34 versus 0.38/10,000) while VBAC was associated with significantly increased perinatal mortality compared with planned or emergency repeat caesarean section  (1.3 versus 5/10,000)17

In order to decrease the repeat caesarean section rate in justifiable cases such as those with previous one caesarean section, need to encourage VBAC and the couple must have complete discussion on VBAC during their Antenatal visits before final decision of mode of delivery. Infrastructure and human resources and training for VBAC needs to be improved in order to achieve successful VBAC. In addition primigravidas should be the real focus of interest for spontaneous vaginal delivery as it will reduce caesarean section rate due to repeat caesarean sections. In order to achieve the target proper antenatal checkups, thorough counselling, antenatal exercise classes and constant support by the companion during labour are necessary.18

The second commonest indication for caesarean section is IUGR and oligohydramnios (15.5%) followed by fetal distress (7.8%). Poor Antenatal attendance and malnourishment especially iron deficiency anemia are the main reasons for IUGR. In addition multiple other factors like young age, primigravida status, low gestational weight gain, previous history of abortion, pregnancy induced hypertension (PIH) and gestational diabetes mellitus (GDM) have also been associated with IUGR.19

Awareness and importance for Antenatal visits should be ensured which would eventually help in succeeding the goal of reduced maternal morbidity and mortality.20

The conclusion of this study is that the frequency of Caesarean section is 21.1% which is contributed largely by the woman with previous Caesarean section followed by Intrauterine fetal Growth Restriction (IUGR) and Oligohydramnios. 

Conflict of interest- None

Financial support: None

Potential competing interests: None

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