PREVALENCE OF CAESAREAN SECTION AND THE ASSOCIATED FACTORS IN PRIVATE HOSPITALS IN ADDIS ABABA a CROSS SECTIONAL STUDY

ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCES SCHOOL OF PUBLIC HEALTH MASTER OF PUBLIC HEALTH RESEARCH THESISPREVALENCE OF CAESAREAN SECTION AND THE ASSOCIATED FACTORS IN PRIVATE HOS

ADDIS ABABA UNIVERSITY COLLEGE OF HEALTH SCIENCES SCHOOL OF PUBLIC HEALTH MASTER OF PUBLIC HEALTH RESEARCH THESIS

PREVALENCE OF CAESAREAN SECTION AND THE ASSOCIATED FACTORS IN PRIVATE HOSPITALS IN ADDIS ABABA - A CROSS-SECTIONAL STUDY

By: Ayodeji Olanipekun (MBBS)

A THESIS SUBMITTED TO THE FACULTY OF PUBLIC HEALTH, SCHOOL OF

FULFILLMENT OF THE REQUIRMENT FOR THE DEGREE OF MASTERS OF PUBLIC HEALTH IN REPRODUCTIVE HEALTH (MPH/RH)

Advisors: MS Meselech Assegid (BSC, MPH)

DR Yirgu G/Hiwot (Department of Obstetrics & Gynaecology)

June 2017 Addis Ababa, Ethiopia

ADDIS ABABA UNIVERSITYCOLLEGE OF HEALTH SCIENCESSCHOOL OF PUBLIC HEALTH

PREVALENCE OF CAESAREAN SECTION AND THE ASSOCIATED FACTORS INPRIVATE HOSPITALS IN ADDIS ABABA - A CROSS-SECTIONAL STUDY

Table of contents

Acknowledgement I Acronyms II Summary VIII

1 Introduction 1

1.1 Background 1

1.2 Statement of the problem 3

1.3 Significance of the study 4

2 Literature review 5

2.1 Rising trend in the prevalence of Caesarean delivery 5

2.2 Non-medical factors 6

2.2.1 Age of the mother 6

2.2.2 Level of education 6

2.2.3 Socio-economic and insurance status 7

2.2.4 Other non-medical determinants 8

2.3 Medical factors associated with Caesarean delivery 8

2.4 Conceptual framework 10

3 Objective 12

3.1 General objective 12

3.2 Specific objectives 12

4 Methods 13

4.1 Study design 13

4.2 Study area 13

4.3 Population 13

4.3.1 Source population 13

4.3.2 Study population 13

4.3.3 Inclusion criteria 13

4.3.4 Exclusion criteria 13

4.4 Study period 13

4.5 Sample size estimation 14

4.6 Sampling procedure 14

4.7 Data collection procedure 16

4.8 Data quality control 16

4.9 Variables 16

4.9.1 Independent variables 16

4.9.2 Dependent variables 16

4.10 Operational definitions 17

4.11 Data processing and analysis 17

4.12 Ethical considerations 17

4.13 Dissemination of research findings 18

5 Results 19

5.1 Sociodemographic characteristics 19

5.2 Past obstetrics history 21

5.3 Current obstetrics history 22

5.4 Bivariate and multivariate analysis 26

6 Discussion 29

7 Conclusion 32

8 Recommendations 33

9 References 34

8 Annexes 39

1 Information sheet 39

2 Consent form 40

3 Questionnaire in English 41

A Information Sheet, consent form, questionnaire (In Amharic) 45

List of tables Table 1: Socio-demographic characteristics of respondents 20

Table 2: Past obstetrics history of respondents 21

Table 3: Current obstetrics history of respondents 23

Table 4: Bivariate and multivariate analysis ……….……… 27

List of figures Figure 1: Conceptual framework 11

Figure 2: Schematic presentation of sampling procedure 15

Figure 3: A pie chart showing the mode of delivery 24

Figure 4: A pie chart showing the type of Caesarean delivery 25

Figure 5: A bar chart showing the varying indications for Caesarean delivery 26

To all the parturient who volunteered their time to take part in this study shortly after delivery.

To all my classmates, especially Helen Tesfayohanes and instructors at the School of PublicHealth for their support and encouragement during this research

To Akateh Derek, for being a friend that stuck closer than a brother during our stay in AddisAbaba and contributing immensely to this thesis

To my beautiful wife and my lovely daughters (Bridget and Bethel) for staying strong while Iwas away from home

Lastly to God almighty, the giver of wisdom

AAHB – Addis Ababa Health Bureau

AAU – Addis Ababa University

USA – United States of America

WHO –World Health Organization

Background: Caesarean delivery has been increasing at an alarming rate globally This increase

has become a major challenge across health institutions in both developed and developingcountries Caesarean delivery rate has been shown to be more common in the private fee–for–service hospitals than public hospitals The Ethiopia Demographic and health survey reported anincrease in the caesarean delivery rate between 2005 and 2011 from 16% to 21.8% and even ahigher rate among women who delivered in private health institutions (41.7%) which was twicehigher than their counterparts who delivered in public institutions (20.6%) signifying thepossibility of over-utilization of the service in the private hospital

Objective: To determine the prevalence of Caesarean delivery and the associated factors in

private hospital in Addis Ababa

Method: This study was a facility based cross-sectional survey carried out in private hospitals in

Addis Ababa during the months of April to May 2017 Study participants were selected usingmulti-stage random sampling technique Four hundred and eleven consecutive delivered motherswho consented from the selected private hospitals providing basic and comprehensive obstetricsservices participated in study A pre-tested structured questionnaire was used to obtaininformation from the respondents Data was entered in Epi Info version 7 and exported toSTATA version 12 for analysis Multivariable analysis was carried out Strength of associationsand significance level was examined using odds ratio and 95% confidence intervals respectively

Result: The prevalence of Caesarean delivery in private hospitals in Addis Ababa was 63.7% [CI

(59.1%, 68.3%)] Being primiparous [AOR=2.89, 95% CI (1.19, 6.98)], multiparous[AOR=10.2, 95% CI (4.13, 25.4)], previous Caesarean delivery [AOR=12.48, 95% CI (6.01,25.95)] and having health insurance coverage were found to be positive and statisticallysignificantly associated with having Caesarean delivery

Conclusion: Limiting primary Caesarean delivery to the barest minimum by only performing

such for only absolute indications, allowing vaginal birth after Caesarean section (VBAC)through close monitoring during labour, counselling of parturient at the antenatal clinics onpossibility of VBAC and the risks associated with unnecessary request for Caesarean sectionwould be important to decrease the high prevalence of CS

1 Introduction

1.1 Background

The delivery of the foetus is one of the most highlighted events worldwide irrespective of the route

of delivery; however Caesarean delivery has been increasing at an alarming rate globally Thisincrease has become a major challenge across health institutions in both developed and developingcountries The United States of America (USA) reported a Caesarean delivery rate of 32.2% in 2014,this represent a steady increase from the rate of 22.8% reported in 1993.[1,2]

Caesarean delivery rate has been shown to be more common in the private fee–for–service hospitals

Similarly the Caesarean delivery rates also exceed 20% in most other developed regions of the world(with the exception of Eastern Europe).[5]

The leading country in terms of the highest Caesarean delivery rate globally is Brazil with a reportedrate of over 50% in 2010, this shows the rising cesarean rate of 1.2% each year from the 30.3%reported in 1978.[6,7]

In Sub-Saharan Africa, being a low resource setting, the overall reported rate for CD is quite lowbetween 1-2%, however differential rate has been reported between urban and rural areas withhigher prevalence of CD in urban areas.[3,8]

In Nigeria, Giedam et al evaluating the rising trend and indications of Caesarean section at a

The national review of Caesarean delivery in Ethiopia reported a rate of 15% and 18% for CD inpublic hospitals and overall institutional rates respectively.[10,11]

The Ethiopia Demographic and health survey also reported an increase in the caesarean delivery ratebetween 2005 and 2011 from 16% to 21.8% Gebremedhin evaluating the trend and socio-demographic differentials of Caesarean section rate in Addis Ababa, Ethiopia: analysis based onEthiopia demographic and health surveys data reported even a higher rate among women whodelivered in private health institutions (41.7%) which was twice higher than their counterparts whodelivered in public institutions (20.6%) signifying the possibility of over-utilization of the service inthe private hospital.[12,13,14]Tsega et al evaluating the prevalence of Cesarean Section in urban health

facilities and associated factors in Eastern Ethiopia reported even a much higher prevalence of CS

These figures all exceed the 1985 World Health Organization (WHO) announced maximum

The International Federation of Obstetricians and gynecologist (FIGO) in their statement aboutCaesarean Section states that ‘Some countries have experienced increasing recourse to Caesareandelivery for non-medical indications FIGO considers surgical intervention without a medicalrationale to fall outside the bounds of best professional practice Caesarean delivery should beundertaken only when indicated to enhance the well-being of mothers and babies and improveoutcomes’ (FIGO 2014).[17]

The factors responsible for Caesarean delivery are very complex and, in addition to clinicalsymptoms, it is also dependent on the economic, organizational, and socio-cultural status of

Several factors has been evaluated to be explain this increase in Caesarean delivery rate, theseinclude medical, non-medical and health service reasons However the growing consensus presently

is that medical reasons cannot completely explain this increase There are strong evidences to

Available studies on this topic in Ethiopia has majored on the medical factors responsible for risingCaesarean delivery rate, there is paucity of data on the non-medical determinants in private hospitals

in Addis Ababa, Ethiopia

This study assessed both the non-medical and medical factors associated with Caesarean deliveryrate in private hospitals in Addis Ababa

1.2 Statement of the problem

With significant improvement in the choice of anaesthesia, surgical techniques and availability ofblood transfusion services and potent antibiotics Caesarean delivery has become a much saferprocedure, however it is still associated with potential clinical short and long term risk to the motherand the foetus such as haemorrhage, injuries to abdominal organs, wound infection, uterinesynaechie, secondary infertility etc when compared with spontaneous vaginal delivery Also,Caesarean delivery is also associated with increased cost to the health care system and the patientwhich is highly important in low resource economic setting Gonzalez- Perez et al in a study inMexico reported that the extravagant Caesarean delivery is associated with extra cost running intoseveral millions of dollars yearly and this leads to noticeable impact on the country’s economy.[20]Inthe United Kingdom, a newly developed economic model examining the cost of Caesarean deliverydue to non- medical factors showed that annually around 10.9 - 14.8 million additional pounds must

be spent by the health system and the mean saved expenses for each normal vaginal delivery and

In the context of Ethiopia, the World Health Organization (WHO) global study in 2010 estimated thefinancial implication of unnecessary Caesarean delivery in Addis-Ababa in terms of hospitalconsumables, length of stay in the hospital after surgery, human and time resources and cost ofpotential complications from surgery to be 132.7 US dollars per procedure With a reported 4,076unnecessary Caesarean delivery conducted in Addis Ababa in 2010 the total cost incurred will be

It is therefore highly important to determine both the medical and non-medical factors associatedwith increasing Caesarean delivery in private hospitals in Ethiopia where the Caesarean delivery rate

is reported to be about 41.7%[14], Ethiopia being a low income country has other more pertinenthealth concerns and such resources saved from excessive Caesarean delivery can be invested intackling such

Existing studies on this topic in Ethiopia has focused more on public hospitals and the medicaldeterminants for CD

This study determined both the non-medical and medical factors associated with Caesarean delivery

in private hospitals in Addis-Ababa, Ethiopia

1.3 Significance of the study

The higher rate of Caesarean delivery in private hospitals compared to government hospitals is alsoassociated with huge cost; evidences available are pointing more towards non-medical factors asbeing a major factor for this increase

This study aimed to determine both the medical (CPD, fetal distress, previous CS, malpresentation,dysfunctional labour etc) and non-medical factors such as maternal age, level of education,occupation, economic status, health insurance coverage etc which are associated with Caesareandelivery in private hospitals in Addis-Ababa, Ethiopia

The result from this study will help to better understand the important factors responsible forsustaining these trends of increased caesarian section rate in their broader context; it will also helpthe government to develop appropriate policies and guidelines for performing and monitoringcesarean deliveries in the country

Several authors have explored the determinants of the rising trend in Caesarean delivery in differentcontext; however this issue remains a complicated and debatable important health concern Thesedeterminants has been grouped by authors as medical or clinical, non-medical (socio-economic,cultural and demographic factors) and institutional/Obstetrician factors This review of literatureaims to address both the non-medical and medical factors.

2.1 Rising trend in the prevalence of Caesarean delivery

The prevalence of CD has been increasing globally and differential exists between private and publichospitals Globally CD rate has been reported to have increased In the United States of America the

In Brazil which is one of the countries with the highest CD worldwide rate of over 50% in 2010,

there are significant differences between the prevalence of CD among the private and publichospitals Viera et al in 2015 reported the prevalence of Caesarean delivery were 29.9 % and 86.2 %

al reported that the percentage of CD rose from 45.2% in 2012 to 57.3 % in 2015 with a significant

In Ethiopia, there has been a gradual increase in the CD rate with significant differences between theprivate and public hospitals Gebremedhin reported that the CD rate increased significantly from2.3% in 1995–1996 to 24.4% in 2009–2010 From 2003 onwards, it persisted above 15% Also hereported that the rate of CD among parturient who delivered in private health institutions was twice

2.2 Non-medical factors

Non-medical factors that have been studied as being responsible for increasing prevalence of CDglobally include: age of the mother, level of education, socio-economic status, insurance coverage,maternal demand, religion, employment status, and parity

2.2.1 Age of the mother

The age of the parturient is one of the non-medical factors that have been considered to be associatedwith rising CD globally

Elena et al in a study on the epidemic of the Cesarean Section in private hospital in Puebla, México

in 2015 reported that the age of the women was directly associated with decision to perform CD Thefrequency of CD was reported to be higher as the mother’s age increased and the vaginal birthdecreased as mother’s age increased, and this was noted to increase significantly in those womenwho were older than 30 years old and generally the decision for CD is taken by the mothers withoutmedical reason In this study there was significant difference between the ages of women who

Abebe et al evaluating the factors leading to cesarean section delivery at Felegehiwot referralhospital, Northwest Ethiopia also reported that women in the age category of 15–19 had 37 % lower

Kahsay et al studying the determinants of CD and its major indications in Adigrat Hospital, NorthernEthiopia also reported that mothers aged 35 years and above were 3 times more likely to deliver by

2004 reported that even in the absence of complications among older parturient the rate of CD was

2.2.2 Level of education

The level of education has also been shown to correlate with the choice of delivery; howeverfindings from different studies have been inconsistent In Mexico, higher level of education wasassociated with increased choice for CD; more than 56.7 % of the mothers with graduate educationhad CD in the private facility as compared to 18% in public hospitals, also the prevalence of CD

times more likely to have a cesarean section as compared to illiterates.[29] These findings are alsoconsistent with findings in Ethiopia where higher level of education was associated with increasedprevalence of CD (higher education-33.3%, secondary education-32.3%, primary education-15.8%,illiterates-14.8%).[14] This was also consistent with the findings from a study by Bayou et alevaluating pattern of CD in Addis Ababa which reported highest CD rate among women who had

and prevalence of CD.[31]

2.2.3 Socio-economic and insurance status

Several studies have found socio-economic status and insurance status to be significantly associatedwith CD.[14,24,30,31,33]

The findings reported in a Mexican study[24] showed that parturient with a stable socioeconomicstatus opted to deliver in the private hospitals in order to evade all the administrative procedure inthe public hospital that is also associated with a poor medical attention due to the quantity of womenthat each doctor has to attend daily The highest rate of cesarean section found in the privatehospitals could be explained by the economic incentives to doctors, which are usually three timeslarger than those obtained with a vaginal birth, in a cesarean procedure in México a doctor couldearn between $1000-2900 USD in the private sector However, economic incentives do not explainwhat happens in the public hospitals where doctors do not receive extra payment for performing acesarean section In the context of Ethiopia [14], CD rate were increased across all the level ofhousehold wealth index (Rich, Middle-income, poor), however the highest prevalence of CD was

women who have limited financial barriers may over-utilize the service In contrast employmentstatus did not alter the prevalence of CD as the CD rate among the unemployed and the employedwere almost the same (21.7% vs 21.2%)

The type and level of insurance coverage for parturient is another important non-medicaldeterminant for increasing CD which has been studied.[35-39] Studies in the US has shown higherprevalence of CD among parturient under private insurance coverage (high financial support) than

reported than in Iran with a 74.6% total insurance coverage in the population under study In this

study, complementary insurance coverage was also offered to the parturient, this covered 40.4% and8.8% of women with CS and NVD, respectively The result showed higher prevalence of CDcompared to NVD among those who were covered with insurance (52.8% vs 47.2%), moresignificantly the CD rate was much more increased among those who received complimentaryinsurance compared to those who did not (81.5% vs 18.5%).

One of the reasons adduced for this significant increase may be the fear of legal or penal problemsand the lack of clear and adequate laws and regulations to support specialists as well as the lack ofnecessary standards and sufficient insurance coverage and support regarding medical procedures Arecent study in Ethiopia also agree with above findings showing that the prevalence of CD washigher among women in high socio-economic class (27.6%), high-wealth quintile (20.2%) andwomen who had health insurance coverage (30.4%)[30], however it is important to note that thisstudy analysed data from information provided by mothers from their last pregnancies andchildbirth

2.2.4 Other non-medical determinants

The other non-medical determinant that has been discussed in literature as contributing to increasingrate of CD globally include the parity of the parturient, marital status, avoidance of pain by thepatient during NVD and provider convenience.[14,25,26,40,41]

Higher CD has been reported among Nulliparous women and the prevalence decreases with higher

commoner in nulliparous women

2.3 Medical factors associated with Caesarean delivery

The leading medical indications for Caesarean delivery in several studies were; non-reassuring fetalstatus or fetal distress, failure to progress in labour or arrest of dilatation, previous Caesareandelivery, malpresentation and hypertensive disorders in pregnancy (pre-eclampsia andeclampsia).[42,43,44]

In developed countries, the rising trend in Caesarean delivery rates was more related to previous

countries, where the leading medical indication for Caesarean delivery is fetal distress anddystocia.[45,46] Consequently, there is a trend of performing more elective Caesarean deliveries indeveloped countries than in developing countries where majority of Caesarean sections are

performed as emergency procedures.[47] Barber et al in a study in the United States of Americaexamining the indications for Caesarean section to describe factors contributing to increases inCaesarean delivery rate found that primary Caesarean sections contributed to 50% of the increase inCaesarean section rate, the rest being repeat Caesarean sections Considering the primary Caesareansections, more subjective indications like non-reassuring fetal heart rate status contributed more tothe rates than the more objective indications like malpresentation, cord prolapse and abruptioplacenta.[42] The study concluded that modifiable factors were involved and that it is possible toreduce Caesarean section rates.

Other clinical factors like multiple pregnancy, macrosomia, ante-partum haemorrhage, and failedinduction contributed less significantly to the rise in Caesarean section rates.[42]

In a recent systematic review to examine the rising trend in Caesarean section worldwide, Elena et al

[48]

showed that the most frequently reported CS indications were; cephalo-pelvic disproportion(CPD), fetal distress, prior cesarean, dysfunctional labor and elective cesarean Among theseindications, the majority of them were maternal indications and only one represents a fetalindication However the indications were different among countries and the health sector analyzed,for example Chanrachakul et al [49] showed that in Thailand a previous Caesarean was the mostprevalent indication in private hospitals (63%), followed by failure to progress (22%) in the publicsector Otherwise a study in México, established that the main indication in both sectors wereprevious CD with a prevalence of 40.8% in private hospitals and 38.5% in public hospitals Fetaldistress was the prior indication in the private sector (9.5%) and (9%) in a public one; the second

the common indications: malpresentation (28.1%), prior cesarean delivery (28.1%), dysfunctional

indications in Sub-Saharan Africa, the most common indication was obstructed labour (31%).Otherindications included poor presentation (18%), previous Cesarean section (14%), fetal distress (10%),

It was established in Ethiopia that CPD (34%) was the main indication, followed by fetal distress

Ayano et al also showed that the leading indications for CD were, cephalo-pelvic disproportion(38.1%), previous CD (18.9%), fetal distress (12.5%), mal-presentation and malposition (7.1%), and

antepartum haemorrhage (6%).[52] This finding were consistent with similar studies inEthiopia.[25,26,53]

to increase in Caesarean delivery

Medical/clinical factors involves a wide range of maternal or foetal clinical indications forCaesarean delivery such as previous Caesarean delivery, cephalo-pelvic disproportion, labourdystocia, malpresentation, fetal heart rate irregularity, multiple gestation and suspected foetal

Institutional/Obstetrician factors include: economic incentives where CD are performed for financialgains, time management where the Obstetrician perform CD due to lack of time to monitor thepatient to achieve vaginal delivery and also risk minimizing behaviour in order to avoid medico-

Despite the proven safety of Caesarean delivery, there are grave consequences that could follow theincreasing CD especially to the mother and the institutions/Obstetrician These include physical andpsychological cost on mother also economic cost on the patient and health institution

Figure 1: Conceptual framework

CLINICAL REASON

MEDICALIZATION

CAESAREAN DELIVERY

There are eleven public hospitals of which five are owned by the Addis Ababa Health Bureau(AAHB), four by the Federal Ministry of Health (FMOH) and one (Tikur Anbesa hospital) which isunder the Ministry of Education There are also 35 privately owned hospital and 3 Non-Governmental Organization (NGO) hospitals More than 90% of the privately owned hospital offermaternity services.[55]

4.5 Sample size estimation

The sample size (n) required for this study was calculated using formula for a single population proportion (p) by taking the proportion of Caesarean delivery in private hospital in Addis Ababa

size was 374 by considering 10% non-response rate the final sample size was 411

of private hospital in each sub-city The numbers of study participants in each private hospital wasdetermined using proportion to population size where the total sample size was proportionallyallocated to the selected private hospital according to the total number of deliveries in each facility tomeet up the study sample size All delivered mothers who consented at the level of the selectedhospitals were included in the study till the proportion in the hospital was met

Figure 1: Schematic presentation of sampling procedure

10 sub-cities in Addis Ababa City Administration, Ethiopia

Simple Random Sampling Technique

5 sub-cities selected by simple

4.7 Data collection procedure

Data was collected from mothers within 24 to 48 hours after delivery in the postnatal unit of eachselected hospital by using structured standard questionnaire adopted from other researches Trainedinterviewers administered pre-coded and pre-tested questionnaire after they obtained informedconsent from mothers The questionnaire included information on demographic data, socio-economic status, past and current obstetric history and mode of delivery The questionnaire wasdeveloped in English and later translated into Amharic, the local language of the city andconsistency and accuracy check was done to ensure proper and correct translation of the questions

by back translation to English The questionnaire was pre-tested and findings from the pretest wereused to modify the questionnaire Medical records of parturient were used to extract informationsuch as last menstrual period, gestational age at delivery, type and indication for Caesarean sectionand birth weight of the fetus

Data collectors and supervisor who were fluent in the local language were recruited and trainingwas given to them on the purpose of research and techniques/skills on interview, sampling andethical issues, emphasizing the importance of safety of participants and interviewers, minimization

of under reporting and maintaining confidentiality

4.8 Data quality control

The filled questionnaires were checked for completeness and consistency daily by the supervisorsand principal investigator (PI) Supervision was done in-process as well as daily supervision of thecompleted questionnaires by the supervisors and PI for any needed clarifications based on the study.The PI visited each site to oversee data collection process and checked all previously completed

questionnaires for consistency and completeness.

4.9 Variables

4.9.1 Independent variables

The independent variables for this study were: age of the mothers, parity, level of education,monthly family income, health insurance coverage status, occupational status and medicalindications such as CPD, fetal distress, previous CS, malpresentation, obstructed labour etc

4.9.2 Dependent variables

The dependent variable for this study was Caesarean delivery regardless of whether elective oremergency Caesarean delivery

4.10 Operational definitions

Caesarean delivery or Caesarean birth: an operation for delivering a baby by cutting though the

mother’s abdomen and uterus CS was considered irrespective of whether it was performed as anemergency or elective procedure

Emergency caesarean delivery: an unplanned for caesarean section delivery.

Elective caesarean delivery: caesarean delivery done before the onset of labour in the absence of

emergent situations that mandates urgent delivery

Vaginal delivery: birthing one or more young via the vagina irrespective of whether an instrument

was used

Nulliparous: parturient without previous delivery

Multiparous: parturient with previous two or more delivery.

Grandmultiparous: Parturient with five or more deliveries

Medicalization of caesarean delivery: process of using a medical language to justify indication for

caesarean delivery

4.11 Data processing and analysis

Filled questionnaires were checked for completeness and coded by the PI Data was entered onEpiInfo version 7 and exported to STATA version 12 for analysis Frequencies were generated forcategorical variables and summary measures for continuous variables Tables and graphs were used

to present the data Descriptive statistics was used to show the frequency and percentage of thecharacteristics Cross tabulations (chi-square) were computed to establish relationships among thevariables Logistic regression (binary and multiple) analyses were used to determine the effect offactor(s) on the outcome variable and to control possible confounders Bivariate analysis was doneand variables with P- value < 0.2 and other variables that have been shown to be associated with CDwere subjected to multiple regression, P-value < 0.05 was considered to declare statisticalsignificance

4.12 Ethical considerations

Ethical clearance was obtained from the Research and Ethics Committee of School of Public Health,Addis Ababa University and the Addis Ababa City Administration Health Bureau public healthresearch and emergency management core process Permission was obtained from the various healthfacilities managers All measure to maintain human rights including informed consent; the right to

participate in the study, right to privacy and confidentiality and right to prevention from any type ofharm was taken into consideration All Participants were informed about the objectives of the studyand that their participation was on voluntarism basis It was also clearly stated to the participants thatthe information they provided whether orally or in writing were for research purposes and strictlyconfidentially.

4.13 Dissemination of research findings

The final result of the study will be submitted to Addis Ababa University School of Public health,Federal Ministry of Health, Addis Ababa City Administration Health Bureau and the managers ofthe various health facilities in soft and hard copies Presentation and publication of result will becarried out accordingly

5 Results

5.1 Socio-demographic characteristics

Table 1 shows the socio-demographic characteristics of the respondents

Four hundred and eleven parturient participated in this study The age of the respondents rangedbetween 16 – 42 years with a mean of 27.6 ± 4.61 Majority 190(46.23%) of the respondents wereaged between 25 – 29 years Most 388(94.4%) of the parturient were married More than one-third(39.2%) had secondary education while only 2.4% had no formal education About one-quarter(25.1) were unemployed

Majority (41.9%) of the respondent were self-employed with most (77.6%) family having a monthlyincome greater than four thousand birr, while only 16(3.9%) had family income less than onethousand birr Most 372(90.5%) of the respondent had no health insurance coverage, while only39(9.5%) had health insurance coverage

Table 1: Socio-demographic characteristics of respondents who delivered in the selected private hospitals in Addis Ababa, Ethiopia between April 1 st and May 30 th ,2017

5.2 Past obstetrics history

Table 2 shows the past obstetrics history of the respondents

Most 220(53.5%) of the parturient were multiparous, 111(27%) were primiparous, 64(15.6%) werenulliparous while only 16(3.9%) were grandmultiparous

Majority 234(67.4%) has had vaginal delivery in the past, 113(32.6%) has had a previous Caesareandelivery Of the parturient that had previous Caesarean delivery, majority (69%) of the CS tookplace in a private hospital, while 31% took place in a public government hospital

Table 2: Past obstetrics history of respondents who delivered in the selected private hospitals

in Addis Ababa, Ethiopia between April 1 st and May 30 th , 2017