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Magnitude of Maternal Complication and Associated Factors among Mothers

Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia

Article · May 2017

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 International Journal of Health Sciences and Research
www.ijhsr.org ISSN: 2249-9571

Original Research Article

Magnitude of Maternal Complication and

Associated Factors among Mothers Undergone
Cesarean Section at Yirgalem General Hospital,
SNNPR, Ethiopia
Tsigereda Tesfaye1, Dr, Dejene Hailu2, Niguse Mekonnen3, Raheal Tesfaye4
1
Medical Surgical Coordinator, Sawla, General Hospital
2
Associate Professor of Public Health, School of Public and Environmental Health, College of medicine and
Health Sciences, Hawassa University, Hawassa, Ethiopia
3
Lecturer, School of Public Health, College of Health Sciences, Wolaita Sodo University, Wolaita Sodo,
Ethiopia
4
Lecturer, Arbaminch Health Science College
Corresponding Author: Niguse Mekonnen

ABSTRACT

Background: Cesarean section is a major surgical procedure in obstetrics worldwide. It saves the life of
the mother as well as the fetus by use of advanced technique, use of antibiotics and blood transfusion.
However, its complications during and after cesarean section pose higher maternal morbidity and mortality
compared to other modes of deliveries in many developed and developing countries. Maternal
complications during and after cesarean sections and associated factors at Yirgalem General Hospital was
not studied.
Objective: To assess magnitude of maternal complications and associated factors among mothers
undergone cesarean section at Yirgalem General Hospital, Southern Nation Nationalities Peoples Region.
Methods: Institution based cross-sectional study was conducted by reviewing charts of 469 mother who
were operated by cesarean section from July 8/2013 to July 7/2015. The sample was estimated based on
specified assumptions and by using Epi Info. Data were collected by 2nd year Integrated Emergency
Surgical Officers (IESO) from September 1-20/2015.and were analyzed using SPSS version 20.0. Both
bivariate and multivariable analysis was carried out to identify factors associated maternal complications.
Results: The overall maternal complication rate was 30.1 % (95%CI 25.9%-34.1%). Living in rural setting
(AOR=3.37, 95% CI:1.68,6.77); maternal age 20-34 years (AOR= 3.98, 95% CI:1.64,9.67); mothers
referred from other institutions (AOR= 2.23, 95%,CI: 1.37,3.65); multi gravid (AOR= 4.99, 95%CI: 2.75,
9.13); grand multi gravid (AOR= 21.03, 95%CI: 9.30,47.50 ), have no history of ANC follow up
(AOR=3.19,95%CI:1.79,5.65) and operation done with general anesthesia (AOR=2.811,95%CI:1.73,4.57)
were found to be significantly associated with maternal complication.
Conclusions: Maternal complication was found to be high. Living in rural setting, maternal age 20-34
years and use of general anesthesia were associated with high maternal complication. Use of appropriate
anesthesia will reduce the occurrence of complications.
Keywords: Maternal complication, cesarean section, Yirgalem.

INTRODUCTION section could be performed as an elective

Cesarean section serves as a salvage procedure when there is a predictable risk to
surgical procedure facilitating rapid delivery the mother or fetus during labor or in the
of the fetus when prolongation of the presence of an identifiable indication for the
pregnancy is deemed undesirable. Cesarean procedure. The procedure is however

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Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers
Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia

undertaken as an emergency when a increased delivery costs, future pregnancies

complication of pregnancy or labor warrants are more likely to be complicated because
quick intervention to deliver the fetus. [1,2] of a primary cesarean section. [10]
Cesarean section is the most July, 2003 American College of
common major surgical procedure Obstetricians and Gynecologist (ACOG)
performed in sub-Saharan Africa countries. news release reported that cesarean birth
[3]
Over the last decade, there has been a significantly increased a woman's risk of a
raising rate of cesarean section. This has pregnancy related fatality (35.9 deaths per
been a source of major concern to health 100,000 deliveries with a live-birth
care providers in many developed and outcome) compared to a woman who
developing countries. The concern stems delivered vaginally (9.2 deaths per
from the fact that cesarean section is 100,000). [11]
significantly associated with higher risk of The risk and safety of cesarean
maternal morbidity and mortality compared section differ from place to place in respect
to vaginal delivery. [4] to structural development of health system.
Aseptic and antiseptic methods with Although caesarean section is now safer
antibiotics therapy, use of blood transfusion than it has never been, it can never be
and improved anesthesia have all entirely safe and therefore, is not an
contributed to the dramatic decrease in alternate to vaginal delivery. [12]
mortality seen during the last. [5] Despite In Africa, cesarean sections are still
these improved results, considerable care is performed in harmful conditions for saving
still required to maintain and improve the the mother and fetus. It has been shown that
rate of maternal and prenatal morbidity and the risks of surgical complication are greater
mortality. The majority of cesarean with emergency compared with elective
deliveries are performed for condition that cesarean section. [13]
might pose a threat to both the mother and In Ethiopia, the overall institutional
the fetus if vaginal delivery occurred. [6] rate of cesarean section was 18%, which
Cesarean sections are potentially various between 46% in the private for
morbid procedures with overall infectious profit sector and 15% in the public sector
morbidity rates as high as 25%. [7] In among this three quarter of cesareans were
addition to the increased risk for infections recorded as an emergency and thus, the
with cesarean section, women are exposed magnitude of maternal complication is
to complications such as excessive blood expected to be high. Prophylaxis antibiotics
loss and damage to pelvic organs. Future were given in 94% of reviewed cases;
pregnancies may also be affected. There is nevertheless, 12% of the cases reported
an increased risk of uterine rupture, placenta wound infection there were two maternal
accretes, and placenta previa associated with deaths. [14]
a previous cesarean section. [8] Post- Different studies in Ethiopia indicate
operative complications include that the magnitude of maternal complication
endomyometritis, wound infection, fascial following cesarean section were high and
dehiscence, urinary tract infections, bowel associated with various obstetric factors like
dysfunction, thromboembolic prolonged or obstructed labor. [15,16] To the
complications, and pelvic thrombophlebitis. level of researcher‟s knowledge, maternal
[9]
complications during and after cesarean
In many developed countries, section and associated factors at Yirgalem
women are not allowed to VBAC and must General Hospital (YGH) are not studied.
re-sign to a repeat cesarean section with Therefore, this study was carried out to
each successive pregnancy, exposing them determine maternal complications during
to greater risks with each procedure and and after cesarean section and associated
subsequent pregnancy. Aside from the factors as the knowledge of the study results

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Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers
Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia

will help to increase awareness among hospital of 20%, [18] an absolute precision of
health care professionals for the prevention 4% and 5% level of significance.
of this problem in this hospital.
n = (z α/2)2 p (1-p) = (1.96) 2 0.2(1-0.2)/ (0.04) 2n=384
d2
METHODOLOGY
Study setting
Where n represents sample size, P
This study was conducted in
represents proportion of maternal
Yirgalem General Hospital which is found
complication after caesarean section, d,
in Yirgalem town, Sidama Zone, Southern
represents margin of error and CI represents
Nation Nationalities Peoples Region,
confidence interval 95%.
Ethiopia. It is located 318 kilometers south
Hence, the initial estimated sample
of Addis Ababa, capital city of Ethiopia,
size was 384 Women. Fifteen percent of the
and 45 Km far from regional city. The
sample was added as a contingency
Yirgalem General Hospital is serving as a
considering possible loss due to
teaching hospital, with a catchment
incompleteness of some cards. Therefore,
population of more than 4 million. [17] The
the total sample size determined was 384
hospital has seven departments; Obstetrics
+15%*384 was 442. Sample size for the
and Gynecology is one of the Departments
second objectives was also calculated using
where greater than 820 operations are
maternal age variable greater than 30 and
conducted annually.
prevalence is 13.0, OR, 2.1, power of
Study design and Population
test,80% and p-value of 5% the same
Institution based cross-sectional
formula was used and 15% contingency was
study was employed so as to assess the
added the final sample size is 497 It was
magnitude of maternal complication and
calculated using Epi-Info
associated factors among mothers
Therefore, by comparing sample size
undergone cesarean section at Yirgalem
calculated for two objectives that is
General Hospital, SNNPR, Ethiopia, 2015.
determining the magnitude of maternal
The maternity records of all patients who
complication among mothers‟ undergone
delivered by cesarean section in Yirgalem
cesarean section and identifying factors
General Hospital from July 8/2013 to July
associated with maternal complication
7/2015 were reviewed. All cesarean sections
among mothers undergone cesarean section
attended in the hospital from July 8/2013 to
at Yirgalem General Hospital, SNNPR,
July 7/2015 were taken as source and
Ethiopia. The largest sample size (n = 432)
randomly selected charts of mothers
considering 15% contingency which added
undergone cesarean sections July 8/2013 to
to a total of 497 sample size was used for
July 7/2015 in Hospital were considered
the study.
study population respectively.
Sampling technique
Inclusion and Exclusion criteria: All
The registration numbers of mothers
women who had undergone cesarean
who gave birth by cesarean section from
deliveries during the study period were
July 8/2013- July 7/2015 were traced from
included where as those with incomplete
logbooks. The sampling interval or „k‟ was
records, those re-admitted 7days after
calculated by dividing the total number of
discharge or those with lost chart were
eligible mothers (1219) to the final sample
excluded. Stitch abscess and Episiotomy site
size (497) and the calculated k -value was
infection were also excluded.
approximated and taken as 2. The first chart
Sample size calculation
was randomly selected using lottery method
The sample size was computed for
and the subsequent charts were selected by
magnitude of maternal complication after
systematic random sampling method using
cesarean section based on the estimation of
sampling interval of two.
the proportion of maternal complication in
Data collection methods
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Vol.7; Issue: 5; May 2017
Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers
Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia

Data were collected through injury, prolonged catheterization, febrile

document review (reviewing mothers‟ cards maternal morbidity and death in hospital.
and operation records). Two Integrated Venous thromboembolic: Formation of a
Emergency Surgical officer (IESO) year II clot of deep veins, usually of the lower limb,
students were initially trained and later with swelling, warmth, and erythema,
collected the data being supervised by the frequently a precursor of pulmonary
investigator. The structured data abstraction embolism.
format was pre-tested outside the study area Postpartum hemorrhage: Is defined as
before one week then the main data estimated blood loss of >= 1000ml, fall in
collection process was commenced. HCT >10%, post-operation HCT <25%.
Variables Elective cesarean section: Defined as
Dependent variables operation that was done at prearranged time
Maternal complications during and after during pregnancy to ensure the best quality
cesarean section in the first week of post- of obstetrics, anesthesia, neonatal
operation. resuscitation and nursing services.
Independent variables Emergency cesarean section: Defined as
Age, residence, parity, gestational age, operation that was done immediate,
ANC, medical disease, obstetric unplanned or unscheduled termination of
complications, presentation, indication, pregnancy via cesarean section for the
prophylaxis antibiotics, qualification of ultimate purpose of saving the life of both
surgeons, type of anesthesia and type of the parturient and her offspring.
cesarean section. Prophylactic antibiotic: Refer to a very
Operational definitions brief course of antimicrobial agent initiated
Maternal complications: Are complications just before an operation begins with an
(with at least one of such complications like attempt to sterilize the tissue, but a critically
Intra-operative or post operative surgical timed adjunct used to reduce the microbial
complications, febrile maternal burden of intra-operative contamination to a
complication, postpartum hemorrhage and level that can not overwhelm host defense.
venous thromboembolism which occur Data analysis and processing
during and after cesarean section or dead The data were coded, entered,
within 7 days of postoperative day‟s cleaned and analyzed by using SPSS version
cesarean section). 20.0. Descriptive analysis was carried out to
Intra-operative surgical complications: explore the socio-demographic
Include any damage occurring to adjacent characteristics; magnitude of maternal
organs, including bladder, urinary tract or complication after cesarean section was
bowel, as well as unintentional damage to calculated. Bivariate analysis was carried
the uterus or cervix. out to examine the relationship between the
Febrile maternal complication: Are outcome variable and selected obstetric
complications that have a body temperature factors.
of greater than or equal to 38oC. Some of Factors for which P-value < 0.25
the complications are wound infection, were retained for subsequent multivariable
endomyometritis, septicemia, puerperal analysis using multiple logistic regression
morbidity. and those factors which had P-value <0.05
Severe maternal complication: Includes in the final model were taken as statistically
one of the following hemorrhage, blood significant.
transfusion, hysterectomy, thromboembolic, Quality control measures
and intensive care unit admission, The data abstraction format was
postpartum length of stay, postpartum revised for being complete and appropriate
antibiotics treatment, adjacent internal organ before commencement of data collection.
Possible corrections were made at every end

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Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers
Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia

of the days to check if there were seven mothers (86.8%) delivered by

unnecessary or missing variables. emergency cesarean section.
Ethical considerations
The study protocol was approved Table 1.Socio-demographic characteristics of mothers
delivered by cesarean section in Yirgalem General Hospital,
and ethically cleared by the Institutional July 8/2013 to July 7/2015.
Review Board of Hawassa University, Variables Frequency ( n=469) Percent (%)
Age
College of Medicine and Health Sciences. <20 74 15.8
Official letter of permission was written to 20-34 366 78.0
>=35 29 6.2
the hospital. Information on the studies was Residence
given to the hospital officials and team Urban 146 31.1
Rural 323 68.9
leaders of the respective departments about Referral status
the purposes and procedures. In order to Referred 254 54.2
protect the confidentiality of the Self-referral 215 45.8

information, name or identification number

Table 2: Obstetric characteristics of mothers delivered by
was not included in data abstraction format. cesarean section at Yirgalem General Hospital, July 8/2013 to
Identification of the client was only possible July 7/2015.
Variables Frequency(n =469) Percent (%)
through numerical codes. Parity
One 201 42.9
Two-five 222 47.3
RESULTS >Five 46 9.8
Socio-demographic characteristics of the ANC follow up
mothers Yes 373 79.5
No 96 20.5
During the study period, a total of Medical illness during pregnancy
4519 deliveries were attended in Yirgalem Hypertension 39 8.3
HIV/AIDS 15 3.2
General Hospital, out of which 1219 Diabetes mellitus 15 3.2
(26.9%) women delivered by cesarean Labor status(n=469)
Started 395 84.2
section. Out of the 497charts reviewed, 469 Not started 74 15.8
(94.3%) were eligible for analysis. The Duration of labor
remaining 28 charts (27 with incomplete <24hr 373 94.4
≥24hr 22 5.6
information and 4 lost charts) were excluded Status of membrane
from analysis. Out of the 469 mothers for Ruptured 324 69.1
Not ruptured 145 30.9
whom cesarean sections were performed,
146 (31.1%) were from urban and
323(68.9%) were from rural areas. Two
hundred fifty four (54.2%) of the mothers
were referred from other health facilities
and 215(45.8%) were self-referred. The
mean (±SD) age of the mothers‟ was
25.3(±4.8) years and majority of the
mothers (78.0%) were in the age group of
20-34 years [table1].

Maternal obstetric and medical history

Three hundred seventy-three
(79.5%) mothers visited health facilities for
ANC for the recent pregnancy. Most of the Figure 1, Intra-operative surgical complications of mothers
women, 222(47.3%) were Para 2 to 5.The delivered by cesarean section in Yirgalem General Hospital,
SNNPR, July 8/2013 to July 7/2015.
leading medical diseases were hypertension,
39(8.3%), HIV/AIDS, 15(3.2%) and
diabetes mellitus, 15(3.2). four hindered
MATERNAL COMPLICATION

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Tsigereda Tesfaye et al. Magnitude of Maternal Complication and Associated Factors among Mothers
Undergone Cesarean Section at Yirgalem General Hospital, SNNPR, Ethiopia

The overall rate of complications extension 40(28.4%) (Fig 1). And the major
among mothers who delivered by caesarean post- operative complications were surgical
section were 141(30.1%) with 95% CI wound infection 34(43.0%) and febrile
(25.9%-34.1%). The leading surgical morbidity 45(57.0%) details are presented in
complications during intra-operative (Table 3).
included; hemorrhage, 91(64.5%), incision
Table 3: Post-operative maternal complications of the mothers delivered by cesarean section in Yirgalem General Hospital, SNPPR,
July 8/2013 to July 7/2015
Variables Frequency (n=469) Percentage (%)
Status of women after operation
Alive 459 97.8
Dead 4 0.9
Referred 6 1.3
Postoperative maternal complications
wound infection 34 43.0
Febrile morbidity 45 57.0
Post-operative blood transfused
Yes 83 17.7
No 386 82.3
Amount of blood transfused (n=32)
One unit 45 54.2
Two and above 38 45.8
Length of hospital stay after operation
<5 days 267 57.7
5-7 days 156 33.7
>7 days 40 8.6

Factors associated with maternal analysis in which living in rural setting

Complications (AOR= 3.37, 95%CI: 1.68, 6.77); age group
Bivariate analysis showed that there 20- 34 years (AOR=3.98, 95%CI: 1.64,
was association between maternal 9.67); referral status (AOR= 2.23, 95% CI:
complications and living in rural setting, age 1.37,3.65); multi gravid (AOR= 4.99, 95%
group (20- 34 years), referral status, CI: 2.75, 9.13); grand multi gravid (AOR=
gravidity, had no ANC follow up ,operation 21.03, 95%CI: 9.30,47.50 ); had no ANC
done under general anesthesia, duration of follow up (AOR= 2.23, 95%CI: 1.79,5.65)
operation and emergency cesarean section and operation done under general anesthesia
(Table 4). Those variables which has (AOR=2.81, 95% CI: 1.73, 4.57) were
association at bivariate with maternal found to be significantly associated with
complication were undergone multivariable maternal complications (Table 4).
Table 4: Factors independently associated with maternal complications who delivered by cesarean section in Yirgalem General
Hospital, SNNPR, Ethiopia, July 8/2013 to July 7/2015.
Variables(n=469) Maternal complications Yes No COR(95%C.I) AOR(95%C.I)
Residence
Urban 18 128 1 1
Rural 123 200 4.37(2.54,7.52)* 3.36(1.67,6.77)**
Age
<20 6 68 1 1
20-34 127 298 6.02(2.54,4.26)* 3.98(1.64,9.67)**
>=35 8 21 4.32(1.35,13.86)* 2.14(0.62,7.34)
Referral status
Referred 93 161 2.01(1.33,3.03)* 2.23(1.37,3.65**
Self referral 48 167 1 1
Gravidity
Primigravida 179 22 1 1
Multigravida 118 70 4.83(2.83,8.22)* 4.99(2.75,9.13)**
Grandmultigravid 31 49 12.86(6.84,24.18)* 21.03(9.30,47.0)**
ANC Follow up
Yes 86 287 1 1
No 55 41 4.48(2.80,7.17)* 3.19(1.79,5.65)**
Types of anesthesia
Spinal anesthesia 87 270 1 1
General anesthesia 54 58 2.89(1.86,7.50)* 2.81(1.73,4.57)**
*p<0.25 in bivariate, ** p<0.05 multivariable.

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DISCUSSION in urban areas. Rural women are less likely

In this study, the overall maternal to utilize a health facility than their urban
complications were 30.1% with 95% CI counterparts and this could reflect that
(25.9%-34.1%).This is high compared to cesarean section facilities are either not
other studies conducted in developing available or too far away. Mothers who
countries. Bamako, Mali Hospital, reported come from rural setting usually come after
13.2% [19] and Jimma Hospital, West prolonged labor which renders the mother
Ethiopia reported 20%. [16] This variation for complications.
may be due to the nature of obstetric The present finding showed that
emergency including accidental internal referral mothers from other health
organ injury and blood transfusion and also institutions had 2.23 times higher odds of
the services provided for most referred maternal complication relative to those self
patients or complicated deliveries yield high referred. The reason for this high maternal
maternal complication. complication could be a gap in provision of
This study revealed that a number of quality obstetric care during intrapartum
important socio-demographic, obstetric and period. In addition to this, majority of the
delivery characteristics were found to have a mothers came from outside Yirgalem town
significant influence on maternal after they developed obstetrics
complication of cesarean delivery. These complications and thus, were subjected to
include living in rural setting, age group 20- cesarean section.
34 years, referral status, gravidity, those In this study, mothers who had no
mothers who did not follow ANC for the ANC follow ups for the most recent
recent pregnancy and use of general pregnancy had 2.23 times more
anesthesia during the procedure. These complications compared to those who had
findings are consistent with other studies attended ANC. This might be due to low
conducted different countries in Africa. [9,20- health seeking behavior and delay to reach
23]
health institutions. Even though more
The present study showed that should be done to lower maternal
mothers in the age group of 20-34 years complications by providing better antenatal
were four times more likely to develop care services, basic EmOC at the health
maternal complications compared with facility level is critical to achieve safe
those less than 20 years of age (AOR=3.98, motherhood.
95% CI: 1.64, 9.67). Contrary to this In this study, it was observed that
finding, a report from Bamako G Point mothers for whom operations were done
Hospital revealed that there is no association under general anesthesia were 2.81 times
in age difference. [19] more likely to have maternal complications
In this study, grand multiparty has compared to mothers for whom operations
21.03 times more risk of developing were done under spinal anesthesia. This
maternal complications than primgravida finding is in line with a study done in
(AOR=21.03, 95% CI: 19.30, 47.50). This is Gondar Teaching Hospital. [22] Another
consistent with the study done in Sub- studies conducted in African countries
Saharan Africa. [21] These complications indicated that complicated labor and use of
could be reduced by increasing access to general anesthesia increase the risk of
family planning and reducing unmet need accidental internal organs injury and
for contraception which reduces mortality in hemorrhage due to uterine atony.
[16,19,20,23,24]
this group. These might be due to majority
The result of this study further of the cesarean section done after the
revealed that mothers living in rural settings development of complicated labor, and also
are 3 times more likely to have risk of majority of the operations performed were
maternal complications than those who live on emergency bases either labor started or

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complications occurred. and guidance given me to write this research

thesis.
CONCLUSION AND Also, I am very much grateful to my advisor Dr.
RECOMMENDATION Dejene Hailu (PhD) for his unreserved guidance
The magnitude of maternal and constructive suggestions and comments on
the stage of research topic selection and thesis
complication following cesarean section at writing.
Yirgalem General Hospital was high. This I am also grateful to Hawassa University
study identified that living in rural setting, College of Medicine and Health Sciences,
referral status, maternal age and use of School of Public and Environmental Health for
general anesthesia as important predictors of giving me the chance to prepare this research
maternal complication. Thus, due attention thesis and for their support by assigning the
has to be given for closeness of health research advisors. I would like to extend my
facilities as international standards, referral gratitude to Yirgalem General Hospital
status, as well maternal age and the management, staffs and data collectors for their
consultation of senior before giving general cooperation in providing and capturing the
anesthesia from providers more over necessary information.
Lastly, I would like to thank my friends who
clinician must consider these factors in have given their important inputs during the
maternal care settings. preparation of this research thesis.
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How to cite this article: Tesfaye T, Hailu D, Mekonnen N et al. Magnitude of maternal
complication and associated factors among mothers undergone cesarean section at Yirgalem
general hospital, SNNPR, Ethiopia. Int J Health Sci Res. 2017; 7(5):264-272.

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International Journal of Health Sciences & Research (www.ijhsr.org) 272

Vol.7; Issue: 5; May 2017

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