In this interview, we discuss with Dr. Francis Pebalo Pebolo, co-author of the opinion paper “Is the 14% cesarean section rate in Gulu Regional Referral Hospital justifiable? ” published in the PAMJ Clinical Medicine.

Francis Pebalo Pebolo Department of Reproductive Health, Gulu University, P.O Box 166, Gulu, Uganda

Congratulation on your paper and thank you for choosing the PAMJ Clinical Medicine to publish your research.

Can you tell me a little bit more about yourself and your areas of practice or research?

I am an Obstetrician and Gynecologist, a lecturer, acting Head of Department, Department of Reproductive Health, Gulu University Faculty of Medicine in Uganda. I am a passionate obstetric and gynecological practitioner who believes in evidence-based practice and that the local data available should help us make decisions if we make sense of them.  I have interests in Obstetrics and Gynecological researches, a passionate teacher of Obstetric simulation (including Cesarean Section using cow heart), and surgical procedures an advocate for Sexual and Reproductive Health (comprehensive abortion and family planning).

What prompted you to look into the issue of cesarian section rates in Gulu?

In the 2018/2019 Uganda Health Sector Performance Report, Gulu Regional Referral Hospital (GRRH) emerged with the lowest cesarean section (CS) rates (14%) against the National average for Regional Referral Hospitals (RRHs) in Uganda at 32%. This brought a heated argument among healthcare providers in Uganda, about how doctors in Gulu Regional Referral Hospital Obstetric wards are underperforming. Many Medical administrators look at the performance of a medical team by how many patients they have seen, how many procedures/operations have been done in a given period. This is not the right way of gauging the performances of the whole RRH.

In my resident training in Mulago National Referral Hospital, one of the busiest maternity unit in the world, with close to 100 deliveries including at least 40 cesarean sections in a day, I have learned that the most difficult part of cesarean sections in any setting is the prescription and prioritization of the procedure and not the physical number of CS done in 24hours duty. I came to believe the lower rate of CS in GRRH translates the work done by the team to prevent unnecessary CS and only prescribed the procedure when needed.  A proof to that is the rate of fresh stillbirths, an important marker of the effectiveness of cesarean delivery; Gulu had the lowest at 5/1000 live births after Mbarara regional referral hospital at 4/1000.

It should also be known that the rate of CS in GRRH for the last three financial years has been low, 16% in 2016/2017 year dropping to 12% in 2017/2018 and then rising in 2018/2019 a sign that this has been the trend set in GRRH.

Can you summarize for our non-medical audience the key message of your opinion article?

Cesarean section is good to reduce deaths and other complications to the mother and her unborn baby during labor and delivery. This is adequate when the rate is between 5-15%, above or below this, may be dangerous to the unborn babies or pregnant woman. The cesarean section rate has been on the rise worldwide and the rising is associated with complications to the mothers and their babies. The sure way to reduce this is to reduce the rate among women undergoing the procedure for the first time. It’s also known that the most common reason cesarean section(up to 50%) is done among women for the first time is when they take long in labor (prolonged labor). Decision-making about the progress of labor is therefore very key in curbing the rising rates of cesarean sections.

Reporting and comparing facilities cesarean section as proportions; high or low without looking at the intended outcome benefits of the procedure such as the rates of deaths and complications for the babies and their mothers may make things deceptive. The use of the World Health Organisation Robsons ten group classification is ideal for such comparison.  This is a good tool to compare CS rates in the facility over time and also to compare the rates among facilities and their pattern as they change over time.

CS audit, an organized inquiry into every CS to look at the patients and if CS could have been avoided would be ideal ways of reducing non-obstetrics indicated CS. Doctors influenced CS maybe practice in Uganda, and we can only get to know the burden of this if we audit every CS in our hospitals. This can be done the same way Maternal and Perinatal Death Audit, currently referred to in Uganda as Maternal and perinatal Death Surveillance, has been a very important tool to reduce maternal deaths worldwide. Similarly, cesarean section audits can reduce the rising CS rate in low-income countries, Uganda inclusive.

Why do you think the rates of CS in Gulu remain low compared to the other regions of Uganda that you mentioned in your article?

Health services including CS in public health facilities in Uganda are provided free of charge. Although the policy document states so, there are increasing cases of private practice within public facilities, a situation where doctors illicitly charge patients for procedures including CS within the public sections. This money may be significant in a situation where CS delivery is expected, and, where money is the motivation, decisions for CS will be biased.  GRRH has not seen much of such practices. It is not clear why the practice is low or not there in GRRH but it could be that the hospital is located in poverty-stricken Northern Uganda just recovering from over 20 years of civil unrest. CS-related morbidity and mortality are very low in GRRH, this is attributed to good obstetric practice. GRRH is a teaching Hospital for Gulu University and it's manned by staff from the university and the Ministry of health. It's a training site for intern doctors as well, interns are the first on-call, but all decisions about CS are made by senior doctors in the hospital.  With this number of staff, active monitoring of labor is almost done routinely;  this helps to shorten the period for labor, hence, reducing the incidence of prolonged labor, a common indication of primary cesarean sections.  Vacuum-assisted delivery and assisted breech delivery are routinely practiced in the hospital as well.

The situation is certainly different in places such as Kampala right?

Absolutely, in Kampala, the high CS rates in private practice are attributed to doctors’ influence on monitoring labor vs CS. For an obstetrician to monitor labor, they may need over 8 hours, CS is done in 30mins, yet a doctor is paid 3-5 times for CS compared to when they monitor a mother for normal vaginal birth.

You said in your article that the facility rate of cesarean section in Uganda is expected to rise to 36% by the end of 2021, where will that place in Uganda compare to other countries in the region?

 Rwanda has the Highest facility CS rates 64.2% and 14.6%  for private and public facilities in one report. With a public facility CS rate of 36%, and some private facility CS rates approaching 70%, the CS rate in Uganda might surpass all other East African countries. The Ugandan rate is higher than the estimated sub-Saharan African rates of 7.9% and 12.3% among public and private facilities respectively [1]. It should be noted that the population CS rate has remained low in East African states a sign that there is inequity in the provision of CS among the populace. In Uganda for example, the population rate stands at 4.7%, lower than the WHO recommended 5-15%. Population-based CS rate for Gulu is lower than the national average, 3.3% lowest in Moroto at 1.5%

What do you think should be done to avoid unnecessary cesarian sections in your context?.

Policy on CS audit and surveillance, for unjustifiable cesarean sections, practitioners should be held responsible for such.

Although World Health Organization has increased the threshold for active labor from 4 to 5 cm cervical dilatation, in the future a 6cm threshold would help reduce cases of prolonged labor as many mothers take significant time in dilatation between 4 and 6cm cervical dilatation. Prolonged labor is one of the most common causes of primary CS.

If feasible, the medical insurance company should pay more for normal delivery compared to CS, a move to encourage normal births.

The decision to perform CS is currently based on expert opinion as the most senior members are consulted and they make decisions based on their knowledge and experience. This is subject to biased and there should be a national CS guideline to harmonize decision-making in labor suites.

Do you have any intention to continue working on this subject?

Oh yes. I had a concept about Cesarean Section Audits; A Quality Improvement Initiative to Reduce Primary Cesarean Section Delivery in Gulu Regional Referral Hospital. I wanted to use it to prove that we can reduce CS rates, related costs, and morbidity and mortality in Gulu Hospital. If we get funding and collaborations, this tool is expected to help investigate and in CS decision making. I would also like to compare GRRH and any other hospital using the Robsons Ten Group Classification if resources allow.

What motivated you to publish in an African Journal and, more specifically in the PAMJ?

I have two prior publications with PAMJ. It’s a user-friendly journal and the auditors and reviewers are objective in their decisions. I have not seen them solicit for papers like other journals, besides its indexed to PubMed, I am confident that they are good for sharing our scientific works.

References

Francis Pebalo Pebolo et al . Is the 14% cesarean section rate in Gulu Regional Referral Hospital justifiable?. PAMJ - Clinical Medicine. 2021;5:74. [doi: 10.11604/pamj-cm.2021.5.74.28263]

Yaya, S., et al., Disparities in caesarean section prevalence and determinants across sub-Saharan Africa countries. Global Health Research and Policy, 2018. 3(1): p. 19

Atuheire, E., et al., Spatial and temporal trends of cesarean deliveries in Uganda: 2012–2016. BMC Pregnancy and Childbirth, 2019. 19: p. 132.

Organization, W.H., The Robson classification implementation manual. 2017.

Tanaka, K. and K. Mahomed, The Ten-Group Robson Classification: A Single Centre Approach Identifying Strategies to Optimise Caesarean Section Rates. Obstetrics and Gynecology International, 2017. 2017: p. 5648938.