The determinants of rising CS trends worldwide are controversial and are sometimes blamed on nonmedical indications [13]. Quality assurance in CS is needed to reduce maternal and perinatal morbidity and mortality, especially in low-resource settings such as Uganda. Analysis of CS trends using the RTGCS provides a common starting point for further detailed analysis, within which all perinatal events and outcomes can be measured and compared to inform such quality assurance interventions.
With a retrospective study design to assess 3183 women who delivered at GRRH during the study period, we used the RTGCS to assess the proportion of each group in the obstetric population, the contribution of CS in each group to the overall CS rate and the CS rate within each group. Approximately 9 (0.3%) of these women could not be classified due to missing information for one of the six core obstetric variables in their files. Although this seems to be a small number, it presented a challenge.
Our study revealed that more than three-quarters of the mothers who gave birth at GRRH belonged to groups 3 and 1, representing a low-risk population. This finding aligns with the results observed in studies conducted at other tertiary hospitals in Tanzania and Ethiopia[14, 15]. The low CS rates at GRRH can be attributed to the fact that most of the mothers belong to the low-gestational-risk groups 3 and 1. Furthermore, the high-risk obstetric population, including groups 5, 9, and 10, accounted for only 10% of the total number of mothers who delivered during the study period. The current overall CS rate in this study is comparable to the 14% reported in the previous fiscal year of 2018/2019, and it is lower than one-third of the average CS rate in tertiary hospitals in Uganda. [16] confirmed earlier suggestions that the low CS rates in GRRH patients are justifiable[17].
Despite groups 3 and 1 being classified as low-risk populations, one in ten mothers in these groups underwent CS, accounting for 63.9% of all caesarean deliveries at GRRH during the study period. Similarly, a study conducted at a tertiary hospital in Ethiopia identified group 3 as the primary contributor to the overall CS rate[15]. Our study, however, indicated that group 1 was the second major contributor to the overall CS rate, while a similar study in Ethiopia identified group 5 as the second significant contributor[15]. Similarly, in a similar study at a rural hospital in Tanzania, group 1 was the largest contributor to the overall CS rate, followed by group 3 [14]. These variations may be attributed to differences in the obstetric population and the overall distribution of CS rates across all ten groups[4]. Nevertheless, this suggests high rates of CS, particularly among multiparous mothers with no previous history of uterine scar, which are likely to reduce the likelihood of future vaginal deliveries among mothers delivering at this facility.
The high CS rate among mothers in group 5 in our study aligns with similar findings in other studies conducted in low-income countries. Moreover, it has been identified as a primary contributing factor in several studies [14, 15, 18]. Although the group's contribution to the overall CS rate appears to be negligible, this is attributed to the small obstetric population, which may increase in the future due to rising CS rates among the low-risk population[19]. Of particular interest in this study are the CS rates among mothers with a single previous uterine scar, with close to three-quarters of these mothers undergoing repeat CS. Although it is challenging to discern the indications for repeat CS in this retrospective study, the high rates suggest that most mothers in this subgroup were not given the opportunity for a vaginal birth after caesarean section (VBAC). This finding is consistent with a prospective cohort study in Ethiopia, where up to 62% of mothers with one previous uterine incision had repeat CS [12].
The CS rate in group 10 was lower than that in the reference population of a multicounty survey conducted by Tognon et al., 2019 [14], indicating that mothers in this group had higher rates of spontaneous vaginal deliveries [4]. However, group 10 still contributed significantly to the overall CS rate due to its relatively high-risk population. It is important to note that the CS rate among group 9 in our study did not reach 100% as per the RTGCS reference guide [4].
Several limitations should be noted in this study. The retrospective design with data capture, especially from clinical records, may have led to misallocated cases. Additionally, the definition of foetal viability based on 28 weeks from the last normal menstrual period or an ultrasound scan before 30 weeks, if the last normal menstrual period date is missing, or foetal weight of 1000 g or more could impact case allocation in the groups. This finding may not be generalizable to countries with different viability cut-offs, including the current setting in Uganda, where viability has changed from 28 weeks to 26 weeks according to the new guidelines [11]. Despite these limitations, the findings in this study serve as a starting point to question why a particular group has a high CS rate rather than solely focusing on the rate of this obstetric procedure.