Predictors of Decision to Delivery Interval And outcomes of Caesarean Sections at Kenyatta National Hospital

Abstract

Background: Maternal mortality remains high in Kenya with an estimated 510 maternal deaths reported for every 100,000 live births every year. At the Kenyatta National Hospital (KNH), maternal mortality is estimated to be around 639/100,000 live births, which is slightly higher than the national average. According to the World Health Organization (WHO), most of such deaths are preventable with prompt and adequate medical interventions, with the maximum Decision-to-Delivery Interval (DDI) for category 1cesarean sections (CS) set at 30 minutes. Objective: To describe the predictors for DDI for category 1 and 2 cesarean sections and its effect on maternal and neonatal outcomes and the average cost of hospital stay at KNH. Methodology: A prospective cohort study was conducted at the KNH labor ward between February 2019 and March 2019. Parturients scheduled for caesarean delivery were recruited,and a structured and pre-tested questionnaire used to capture their sociodemographic and obstetric characteristics. The indications for cesarean sections for categories (1 and 2) and the decision to delivery interval wererecorded. After birth, all mothers and neonates admitted to the New Born Unit (NBU) were followed up until discharge, and the incidence of adverse maternal and neonatal outcomes recorded. Finally, the duration of post-operative hospital stay was recorded for all mothers and cumulative cost for delivery retrieved from the NHIF office adjacent to ward 1Ain KNH. Data was exported to SPSS software for analysis and a summary of socio-demographic characteristics, obstetric characteristics, and information about the emergency cesarean presented in tables and charts. The mean duration for decision to delivery interval was compared using the independent samples T-test. DDI was then converted to a categorical variable that represents optimal DDI (≤30 minutes) and prolonged DDI (≥30 minutes) and the Chi-square test used to evaluate the relationship between DDI and maternal and fetal outcomes. The Odd ratio at 95% level of confidence was our measure of association. A P<0.05 was considered significant. The analysis was repeated to reflect a DDI of 60 minutes and the median cost for delivery computed. Results: Two hundred and fifteen (215) parturients (120 category 1 CS and 95 category 2 CS) with a median age of 32 years (17-45 years) were enrolled. The sociodemographic and obstetric characteristics of women scheduled for a category 1 CS and category 2 CS were comparable, save for the number of past miscarriages which was significantly higher among parturients scheduled for a category 1 CS (p=0.038). The presence of a previous uterine scar (37.3%) and labour dystocia (25.4%) were the commonest indications for a CS, but their incidence did not vary significantly by the category of CS of parturients (p=241). The DDI was 173 minutes for category 1 CS and 185 minutes for category 2 CS. DDI was longer than the recommended (30 minutes) for 96.3% of parturients scheduled for category 1 CS and 97% for those scheduled for category 2 CS (p=0.594). At 60 minutes, 9.4% and 8.3% of parturients scheduled for category 1 and 2 CS respectively had delivered (p=0.807). The DDI at 30 minutes and 60 minutes did not influence blood loss (p=0.222) and the post-operative stay of mothers (p=397) significantly. However, at both 30 minutes and 60 minutes, the occurrence of adverse neonatal outcomes was marginal with the risk NBU admission being considerably higher at ≤30 minutes (p<0.001) and ≤60 minutes (p<0.001) DDI. The birth weight and sex of babies were comparable. The median cost for delivery was Ksh 46,577.50.

Conclusions:DDI was 173 minutes for category I CS and 185 minutes for category II CS. Failure to meet the recommended DDI of 30 minutes did not influence maternal outcomes, but increased the risk of neonates having a poor Apgar score at 5 minutes and being admitted to the NBU.