Risk Factors, Indications and Outcomes of Post Cesarean Section Readmission at Knh: a Case-control Study

Abstract

Background: Cesarean section (CS) is one of the most common major surgical procedures in Obstetrics. It is an effective lifesaving procedure in preventing maternal and perinatal mortality and morbidity when medically indicated(8). The rate of CS has been on a rising trend globally(9). Readmission rate is a recognized metric used to measure the quality of healthcare in surgical and medical specialties; the primary goal of this evaluation is to prevent morbidity. Women who deliver through CS are at a higher risk of readmission than those who have had spontaneous or assisted vaginal delivery (13)(14)(15). No studies in sub-Saharan Africa including Kenya have evaluated the risk factors for readmission after cesarean section (CS) which is essential in designing effective readmission prevention interventions. Objective: To determine the risk factors, indications, and outcomes of post-CS readmission at Kenyatta National Hospital (KNH), from January 2014 to December 2019. Methodology: This was an unmatched case-control study in which 107 records of post-CS patients readmitted within 6 weeks postpartum (cases) and 213 records of post-cesarean section patients who were not readmitted (controls), in a ratio of 2 controls to 1 case, after cesarean sections performed at KNH from January 2014 to December 2019. The socio-demographic, intrapartum, postpartum factor and comorbidities were summarized as frequencies or means and compared using Chi-square or student t-test for categorical data and continuous data respectively. Univariate and multivariable logistic regression adjusted for confounding factors were conducted to determine crude and adjusted odds ratios (aOR) and their 95% confidence intervals. Statistical significance was based on a p-value < 0.05. The indications for readmission and outcomes were tabulated and presented as frequencies (percentages) for the cases. The data was analyzed using the STATA version15. Results: Between January 2014-December 2019, 25,449 patients underwent CS at KNH. Of these, records of 107 out of 166 cases and 213 out of 334 controls were eligible. The main risk factors for readmission post CS in KNH were unemployment (aOR 1.87, 95% CI [1.00 - 3.49], P<0.05), referral from another facility for CS at KNH (aOR 2.23, 95% CI [1.14 - 4.33 P<0.05]), induction of labour (aOR4.27, 95% CI [1.94 - 23.34], P<0.05) and intraoperative hemorrhage (aOR11. 50, 95% CI [1.19 - 111.18], P<0.05). The most common indication for readmission was ix due to surgical site infections (72.89%). Fifty-eight percent of the readmitted patients were managed conservatively post-CS while 42.1% had surgical interventions. The median length of stay post-discharge was 3 days. All readmitted patients were discharged home. Conclusion: Main risk factors for post-CS readmission were patients who had been managed at peripheral facilities then referred to KNH for CS, and induction of labour. The most common indication for readmission was due to surgical site infections (72.89%). The average length of stay during readmission was 3 days. Fifty-eight percent of patients were managed conservatively while 42.1% of the readmitted patients required surgical intervention. All patients were discharged home. Recommendations: To reduce readmission post-CS, infection reduction and surveillance should be instituted especially among those with risk factors which include the unemployed, referrals to KNH for CS, and induction of labour. Keywords: readmission, cesarean section, postpartum.