• Users Online: 79
  • Print this page
  • Email this page


 
 
Table of Contents
ORIGINAL ARTICLE
Year : 2021  |  Volume : 6  |  Issue : 2  |  Page : 61-68

Contributing indications that provoke C-section: A study from tertiary care hospitals


Department of Pharmacology and Toxicology, Moradabad Educational Trust Group of Institutions, Faculty of Pharmacy, Moradabad, Uttar Pradesh, India

Date of Submission10-Jun-2021
Date of Decision24-Jun-2021
Date of Acceptance03-Aug-2021
Date of Web Publication6-Jan-2022

Correspondence Address:
Nikhil Singh
Moradabad Educational Trust Group of Institutions Faculty of Pharmacy, Moradabad - 244 001, Uttar Pradesh
India
Login to access the Email id

Source of Support: None, Conflict of Interest: None


DOI: 10.4103/liuj.liuj_73_21

Rights and Permissions
  Abstract 


Background: Both cesarean-section (CS) delivery (CD) and vaginal delivery (VD) is associated with well-known measurable short- and long-term maternal and neonatal complications and benefits. Objective: The present retrospective observational study was conducted on a preliminary basis to evaluate the contributing factors that provoke CS delivery. Materials and Methods: The short-term (6 months) retrospective study was conducted at the Department of Obstetrics and Gynaecology, Pt. Deen Dayal Upadhyay and Northern Railway divisional hospital Moradabad, Uttar Pradesh, India. The sample size was calculated accordingly with a relative precision of 10.2% of prevalence and was found to be 140 and we have taken the sample size of 345. Results: The prevalence of CD for a particular course of duration was found to be 36.23%. The risk of CD increased (P < 0.001) with increased BMI. However, differential limits of normal BMI signify that lower limit of normal BMI possessed high % of CS. As the education profile was getting high the possibility of CS was found to be increased (P < 0.001). Women with negative Rh factor the probability of CS in terms of percentage was found to be 87.5%. There was a proportionate possibility of CS with an increased gap between parities. The % mortality of new-born by CD and VD was 14.28% and 85.71%, respectively, which signifies that CS prevents infant mortality. There was 99.2% possibility of undergoing CS if a woman possessing medical complications. Conclusion: The present study acknowledged that CD ensures feto-maternal safety. However, the study also highlighted some probable indications that might engender CD.

Keywords: Body mass index, cesarean delivery, caesarean-section, fetomaternal, mortality, parity, Rh factor, vaginal delivery


How to cite this article:
Singh N, Srivastava R, Srivastava S, Patel PS. Contributing indications that provoke C-section: A study from tertiary care hospitals. Libyan Int Med Univ J 2021;6:61-8

How to cite this URL:
Singh N, Srivastava R, Srivastava S, Patel PS. Contributing indications that provoke C-section: A study from tertiary care hospitals. Libyan Int Med Univ J [serial online] 2021 [cited 2022 Dec 9];6:61-8. Available from: https://journal.limu.edu.ly/text.asp?2021/6/2/61/335047




  Introduction Top


The cesarean-section (CS) was introduced in clinical practice as a lifesaving procedure both for the mother and the infant.[1] The proportion of CS to the total births is considered as one of the important indicators of emergency obstetric care.[2] The rate of CD has increased dramatically over the past decade. The observation was that in the case of perinatal mortality, there was no benefit of CS for the countries with a high perinatal mortality rate (>20/1000).[3] About 18.5 million CS are performed yearly worldwide and continues to rise in the developed as well as in many developing nations.[4] The rates in many countries have increased beyond the WHO-recommended level of 5%–15%. In high-income as well as low-income countries the rates have gone up phenomenally in the last few decades.[5] In India the average rate was increased from 21.8% to 25.4% with two states, Kerala and Goa, have shown the highest percentage of CS delivery.[6] The rate of CD is relatively much higher in private hospitals rather than in public health facilities.[7]

There was a lack of sufficient evidence to evaluate fully the risk and benefits of planned CD. However, a number of studies have found that cesarean cases at maternal request are actually rare and many personal and societal reasons including fear of labor pain, future sexual dissatisfaction, etc., are behind some reasons.[8] Surgical intervention during pregnancy is usually performed to ensure the safety of the mother and child under conditions of obstetric risks but becomes malpractice.[9]

It is often argued that CS also depends upon the power of decision-making in the home and seeking medicalized health care was associated with higher maternal education, family incomes, and women's fear of the physiological consequences of a normal delivery.[10] There are, for instance, practice styles among physicians, or attitudes among obstetricians, fear of litigation, the physician's convenience, and most importantly, economic incentives may favor and determines the choice of CS delivery. Economic motives may include both doctors' fear of malpractice as well as economic gain.[11] In general, it is argued that besides the medical factors, the physician's interests determine the choice of CS.

Women's height is correlated to the pelvic size and is currently used to predict cephalopelvic disproportion.[12] Umbilical cord prolapses were associated with an increased risk of neonatal hypoxic brain injury and perinatal death. A history of infertility treatment among nulliparous women >40 years old with singleton pregnancies increases the risk for cesarean delivery (CD) independently of other known risk factors. The reported rate of perinatal diagnosis of Cord Entanglement was found to be 23%. Patients with oligohydramnios have significantly higher incidences of fetal heart rate decelerations and CS than patients with adequate amniotic fluid. Neonates with oligohydramnios are twice as likely to develop pulmonary hypoplasia and more likely to experience neonatal death when compared to those with adequate fluid. Induction of labor following CS is associated with a significantly higher incidence of repeat CS in women who have not had a previous vaginal delivery (VD). Lack of progress in labor (also known as dystocia or failure to progress) is a dominant reason for CD. The planned CS is better than the planned VD for the term fetus in the breech presentation.[13]

As CD at one period of time was performed only subsequent to maternal death, but the risk of maternal death has been estimated to be several times due to CD. Still, there are several problems which make it difficult to interpret them. Some reports suggested that there may not be an increased risk of maternal death with elective CD compared with VD however maternal mortality has become rare in affluent countries, but the picture is quite blurred for developing Nations. The risk of maternal death due to CD is significantly high when compared with VD, particularly when performed during labor.[14]

Anesthetic complications, hemorrhage and sepsis, which are mostly preventable in affluent countries, may make major contributions toward maternal mortality in adverse conditions. This needs to be taken into account by clinicians and women when considering the risk-benefit equation.[15] CD is a major surgical procedure and should only be practiced when conditions clearly demand it. The present study will reveal the factors that provoked CD and will also be a major breakthrough in finding out the genuine reasons for dramatically increasing cesarean cases. Research is needed to adequately compare outcomes of planned and unplanned CD. This study will review current research on the rise in CD and its implications related to risks, benefits, ethics, practice, and future research. It includes certain clinical and nonclinical parameters which will help out in assessing, analyzing, and interpretation of the factors that provoked CD. The major clinical parameters will support this up to a great extent to this study.


  Materials and Methods Top


The short-term retrospective study for about 3 months was conducted at Department of Obstetrics and Gynecology, Pt. Deen Dayal Upadhyay Hospital and Northern Railway divisional hospital Moradabad, India. The study was designed to ascertain the short term prevalence of CD and its associated outcomes in Moradabad. The prevalence of CD in India was 10.2%[16] so the sample size required was calculated accordingly with a relative precision of 10.2% of prevalence with a confidence level of 95%, using the formula: Z (1α/2) pq/d. The calculated sample size obtained was 140 but to make study optimized we have taken the sample size of 345.[17] The Body Mass Index 34 and socioeconomic Status 35 of the subjects were calculated in accordance to previous reported studies.[18]

Data collection

A case record form was designed, reviewed by an expert panel and was pre-tested on 25 cases and was scaled up for study. The first section of the questionnaire was designed to project the basic demographic details such as body weight, age, height, diet, personal background (religion, education, occupation, socioeconomic status), etc., While second section of the questionnaire was designed to record clinical manifestations related to pregnancy or delivery like past or present hormonal therapy, postmenopausal complications, gravida parity, duration between successive gravida parity, mode of delivery whether normal or cesarean, etc. with concerned complications. The data were collected using various data sources from IPD/MICU visited patients.

The questionnaire was completed by collecting required data from Maternity records and laboratory investigation reports (if available) of labor/cesarean ward with the cooperation of present staff. The personal interaction with patients or her attendant was done to precise the accuracy of desired parameters which were mentioned in the questionnaire. Informed consent was taken from the subject or representative of the subject before data collection.

Inclusion criteria

  1. Woman hospitalized in the respective hospital
  2. A woman should be above of age 18 years
  3. Postpartum woman available during data collection
  4. Those who are willing to participate actively.


Exclusion criteria

  1. A woman not hospitalized in the respective hospital
  2. A woman less than the age of 18 years
  3. Postpartum woman not available during data collection
  4. Those who are not willing to participate.


Statistical analysis

The groups were compared by applying Fisher's exact test for the analysis of categorical variables, and Wilcoxon's rank-sum test for the analysis of continuous variables that were not normally distributed. A two-sided P < 0·05 indicated statistically significance.


  Results Top


Patient participation was strictly abided by the provisions of inclusion and exclusion criteria and an informed consent form required before their admission in the study. The study includes postpartum hospitalized females and was classified into two groups, i.e., CD and VD. Out of 345 deliveries, 125 were CD and their prevalence for a particular course of duration was found to be 36.23%. The evaluated baseline data are summarized in [Table 1].
Table 1: Caesarean section delivery and its determinant factors

Click here to view


Late-age pregnancy abide cesarean-section

As the age of the mother increases, there was more possibility of going through CS. Mothers aged (30 or more) have greater chances of CS delivery than younger counterparts [Table 1].

Optimized body mass index prevents cesarean-section

The study suggested the effect of body mass index and its known confounders such as gestational age, birth weight, maternal age, and maternal height on CS. The BMI of the mother signifies positive relation of CS with body mass index. The risk of CD increased consistently and significantly (P < 0.001) with increased BMI. However, differential limits of normal BMI signify that maximum births with the least % of CS occurred with the upper limit of normal BMI and lower limit of normal BMI possessed high % of CS. This signifies the inverse relation of CS with differential levels of normal BMI range.

Educational supremacy favours caesarean-section

The maximum number of births cases were of illiterate women but possessed the least % of CS however births belonging to highly educated women was found to show high % of CS. This signifies that as the education profile was getting high the possibility of CS increased that showed the existence of a statistical association between Education and CS (P < 0.001).

Religious intervention favours caesarean-section in Muslims

175 deliveries were belonged to Muslims with 42.85% of CS however 170 deliveries in Hindu possess 29.41% of CS which signifies that there were more CS in the Muslim community among other religions.

Low nutritional value diet might put the mother to cesarean-section

CS was more experience by Non-vegetarian mothers with 42.93% as compared to vegetarians, possessed 27.92% of CS. Junk food eater mothers with 55.46% of CS however Non-Junk food eater mothers experienced only 26.106% of CS. This signifies there was a positive relation of CS with Junk food and non-vegetarian dietary habits.

Rh negative factor: An indication for cesarean-section

As per Rh factor concerned the data represented that majority of deliveries in women are with positive Rh factor with 34.71% of CS cases. Although only 8 births in women with negative Rh factor was found, the probability of CS in terms of percentage was significantly high (87.5%).

Infertility treatment might instigate cesarean-section

Although hormonal therapy improves pre- and post -maternal complications it might instigate CS occurrence. The population taking Hormonal therapy has more probability in terms of percentage (78.84) to undergo CS [Table 1].

Impact of parity on cesarean-section

There was 31.53% of CS during first parity, however a significant increase in CS was found up to third parity (53.65%) but after third parity the occurrence of CS deliveries decreased [Table 2]. In the first parity among the total births, there were five postpartum women which had previous miscarriages. All five women went through CS. In 1st, 2nd, and 3rd parities among the total births there were six postpartum women had previous fetal demised and all 6 women went through CS.
Table 2: Women underwent caesarean section as per parity

Click here to view


Increased parity gap provoked caesarean-section

The gap between successive parity that was taken in months, there was 28.62% of CS with parity gap of 12–24 months however 100% possibility of CS was found with parity gap of more than 48 months that signifies the proportionate possibility of CS with an increased duration between parities [Table 3].
Table 3: Women underwent caesarean section as per duration between successive parity

Click here to view


Cesarean-section results increased bodyweight of new-born

The average maximum weight of new-born is 3.08 kg and the mean weight for all age groups was found to be 2.89 kg. The possibility of CS was increased with increasing baby weight [Table 4].
Table 4: Women underwent caesarean section as per new born weight and gender

Click here to view


Cesarean-section prevents infant mortality

The mortality % of CD was 14.28% however for VD it was 85.71% which signifies that CS prevents infant mortality [Table 5].
Table 5: Women underwent caesarean section as per mortality

Click here to view


Maternal and foetal complications provoked cesarean-section possibility

[Table 6] represented summarized clinical interventions that provoked CS like cephalopelvic disproportion, infertility, cord entanglement, previous fetal demised and meconium stained etc., however major complications include oligohydramnios and previous lower segment cesarean (LSC). The above-mentioned medical complications were major factors responsible for CS. Overall there was 99.2% possibility of undergoing CS if a woman possessing all the above medical complications.
Table 6: Women underwent caesarean section as per medical factors

Click here to view



  Discussion Top


Women today embark on pregnancy at a late age; therefore their chances of undergoing CD were high. Our findings related to maternal age suggested that late age maternity endorsed CS possibility as several studies suggest that women were more prone to complications as the age of pregnancy and delivery increases.[19],[20] This study suggested that the risk of CD increased consistently and significantly with increased BMI but optimized BMI favors the VD because higher BMI increases the rate of cephalopelvic disproportion/Failure to progress which favors CS. It is often argued that the power of decision-making in the home and seeking medicalized health care were associated with higher maternal education and family incomes. The study suggests that the proportion of CS is much higher among mothers having secondary and higher education than without education or primary education. In India, the proportion of CD is very high among mothers with high educational background, which perhaps illustrates that women with higher educational attainment can make decisions about their own health care. Researchers have found a strong correlation between increasing CS deliveries with socioeconomic and cultural factors. In some instances, doctors' preferences for the surgical procedure and women's demands are responsible for the increasing trend of CS which imposed a financial burden on the patients. This study supports the fact that as the majority of CS cases belong to the upper socioeconomic class. Besides, this different rates of CS in public and private hospitals suggested that non-medical factors such as economic gain and pressures of private practice may motivate doctors to perform surgical deliveries. Another factor related to decision-making for CS is giving birth in auspicious time or on some special day. In a country like India, where religion and religious believes takes place before any other things, childbirth in an auspicious day perhaps an important factor for opting surgical intervention. Our study represented the correlation between religious beliefs and CS among different communities and it was found that the majority of CS deliveries were from the Muslim community followed by the Hindu community. It has also been noticed from the voices of women that preference for having birth on some special day for religious and cultural reasons exists which sometime comes from family members or the woman herself opted.[21] The higher order births are less likely to deliver by CS, this fact is supported by our study but only after third parity as delivery complications are significantly lower among higher-order pregnancies. However, this study on the other hand also showed that up to 3rd parity probability of CS was more likely to occur. The factor that provoked for the performance of CS is large size of the baby at birth and the possibility of CS was increased with increasing baby weight. Larger size babies are at higher risk of being delivered by CS. Moreover, babies with birth weight more than 3 kg are also at high risk. In India, CS is widely perceived as safer than vaginal birth for babies.[22],[23] The perinatal mortality, neonatal mortality, or serious neonatal mortality was significantly lower for the planned CS group than for the planned vaginal birth group. The prevalence of obesity in pregnant has reached pandemic proportions across nations. Junk food and nonveg stuffs are considered to have low nutritional values than pure vegetarian diets and also these items were more prone to provoked obesity during pregnancy due to limited or less physical activity. CS in these women poses many surgical, anesthetic, and logistical challenges.[24] We found a significant positive correlation of CS in overweight pregnant women who have Junk food and non-vegetarian dietary habits. The probability of CS in Rh-negative mothers in terms of percentage was significantly high and was supported by the fact that the Rh-negative patients were undergoing CS for the presence of significant fetomaternal hemorrhage.[25] The history of infertility treatment among women > 40 years old with singleton pregnancies increases the risk for CD independently of other known risk factors. Although hormonal therapy improves pre- and post-maternal complications, it might instigate CS occurrence. This study reveals that the population taking Hormonal therapy has more probability to undergo CS. Cephalopelvic disproportion is a major risk factor for maternal and perinatal morbidity and mortality. Women's height is correlated to the pelvic size and is currently used to predict Cephalopelvic disproportion. The pregnancies conceived by IVF and ovulation induction have led to an increase in the number of multiple births and these babies are usually delivered by CS.[26] The reported rate of perinatal diagnosis of Cord Entanglement is only 23% and fetal movements may increase tightening of an already entangled umbilical cord which could lead to occlusion and fetal distress. Patients with oligohydramnios have significantly higher incidences of fetal heart rate decelerations and CS than patients with adequate amniotic fluid. Neonates with oligohydramnios are twice as likely to develop pulmonary hypoplasia and more likely to experience neonatal death when compared to those with adequate fluid. The induction of labor following CS is associated with a significantly higher incidence of repeat CS in women who have not had a previous VD.[27] Many Caesareans are done during the latent phase of labor and in the second stage of labor when it is not prolonged. Repeated lower section caesareans (LSC) and lack of progress in labor (also known as dystocia or failure to progress) are the most common reasons for CD.[28] Number of clinical interventions that provoked CS were reported during the study like cephalopelvic disproportion, infertility, cord entanglement, previous fetal demised and meconium stained etc., however, major complications include oligohydramnios and previous LSC.[29]


  Conclusion Top


This study illustrates the major factors that provoked CD. It acknowledges that the provision of CD is universally accepted as it ensures feto-maternal safety. The mortality of maternal with CD was found to be lower as compared to VD. Although number of studies suggested that CS delivery is a major risk of maternal so the present study suggested that there are some demographic and medical factors which are directly or indirectly molding the occurrence of CS deliveries. At some point, medical advisors and pregnant women can change the scenario of CD of India. It was recommended from the study that the obstetrical interventions should be evidence-based and the intervention should strictly be applied to women with complications.

Acknowledgment

The authors would like to thank the Chief medical superintendent of Pt. Deen Dayal Upadhyay and Northern Railway divisional hospital Moradabad, Uttar Pradesh, India. For giving official permission to conduct the study. Also a sincere thanks to the Administrative, paramedical and medical staff of the Department of Obstetrics and Gynaecology Pt. Deen Dayal Upadhyay Hospital and Northern Railway divisional hospital, Moradabad, Uttar Pradesh (India) for their kind support.

Financial support and sponsorship

This works comes under institutional funding and was funded by Moradabad Educational Trust Group of Institutions Faculty of Pharmacy, Moradabad, Uttar Pradesh - 244 001, India.

Conflicts of interest

There are no conflicts of interest.





 
  References Top

1.
Althabe F, Belizán JM. Caesarean section: The paradox. Lancet 2006;368:1472-3.  Back to cited text no. 1
    
2.
Gabrysch S, Zanger P, Campbell OM. Emergency obstetric care availability: A critical assessment of the current indicator. Trop Med Int Health 2012;17:2-8.  Back to cited text no. 2
    
3.
Miesnik SR, Reale BJ. A review of issues surrounding medically elective cesarean delivery. J Obstet Gynecol Neonatal Nurs 2007;36:605-15.  Back to cited text no. 3
    
4.
Gibbons L, Belizán JM, Lauer JA, Betrán AP, Merialdi M, Althabe F. The global numbers and costs of additionally needed and unnecessary caesarean sections performed per year: Overuse as a barrier to universal coverage. World Health Rep 2010;30:1-31.  Back to cited text no. 4
    
5.
Sufang G, Padmadas SS, Fengmin Z, Brown JJ, Stones RW. Delivery settings and caesarean section rates in China. Bull World Health Organ 2007;85:755-62.  Back to cited text no. 5
    
6.
Thankappan KR. Caesarean section deliveries on the rise in Kerala. Natl Med J India 1999;12:297.  Back to cited text no. 6
    
7.
Padmadas SS, Kumar S, Nair SB, Kumari A. Caesarean section delivery in Kerala, India: Evidence from a national family health survey. Soc Sci Med 2000;51:511-21.  Back to cited text no. 7
    
8.
Tollanes MC. Increased rate of Caesarean sections-causes and consequences. Tidsskr NorLaegeforen. 2009;129:1329-31.  Back to cited text no. 8
    
9.
Young TK, Woodmansee B. Factors that are associated with cesarean delivery in a large private practice: The importance of prepregnancy body mass index and weight gain. Am J Obstet Gynecol 2002;187:312-8.  Back to cited text no. 9
    
10.
Béhague DP, Victora CG, Barros FC. Consumer demand for caesarean sections in Brazil: Informed decision making, patient choice, or social inequality? A population based birth cohort study linking ethnographic and epidemiological methods. BMJ 2002;324:942-5.  Back to cited text no. 10
    
11.
Belizán JM, Showalter E, Castro A, Bastian H, Althabe F, Barros FC, et al. Rates and implications of caesarean sections in Latin America: Ecological study commentary: All women should have a choice commentary: Increase in caesarean sections may reflect medical control not women's choice commentary: “Health has become secondary to a sexually attractive body”. BMJ 1999;319:1397-40.  Back to cited text no. 11
    
12.
Liselele HB, Boulvain M, Tshibangu KC, Meuris S. Maternal height and external pelvimetry to predict cephalopelvic disproportion in nulliparous African women: A cohort study. BJOG 2000;107:947-52.  Back to cited text no. 12
    
13.
Hannah ME, Whyte H, Hannah WJ, Hewson S, Amankwah K, Cheng M, et al. Maternal outcomes at 2 years after planned cesarean section versus planned vaginal birth for breech presentation at term: The international randomized Term Breech Trial. Am J Obstet Gynecol 2004;191:917-27.  Back to cited text no. 13
    
14.
Rotem R, Sela HY, Hirsch A, Samueloff A, Grisaru-Granovsky S, Rottenstreich M. The use of a strict protocol in the trial of labor following two previous cesarean deliveries: Maternal and neonatal results. Eur J Obstet Gynecol Reprod Biol 2020;252:387-92.  Back to cited text no. 14
    
15.
Pathak PK, Singh A, Subramanian SV. Economic inequalities in maternal health care: Prenatal care and skilled birth attendance in India, 1992-2006. PLoS One. 2010;5:e13593.  Back to cited text no. 15
    
16.
Lwanga SK, Lemeshow S, World Health Organization. Sample Size Determination in Health Studies: A Practical Manual. Geneva, Switzerland: World Health Organization; 1991.  Back to cited text no. 16
    
17.
Kuppuswamy B. Manual of Socio-Economic Status Scale. Delhi: Manasayan Publication; 1962.  Back to cited text no. 17
    
18.
Ghosh S. Increasing trend in caesarean section delivery in India: Role of medicalisation of maternal health. Bangalore, India; 2010.  Back to cited text no. 18
    
19.
Taffel SM, Placek PJ, Liss T. Trends in the United States cesarean section rate and reasons for the 1980-85 rise. Am J Public Health 1987;77:955-9.  Back to cited text no. 19
    
20.
Cohen B, Atkins M. Brief history of vaginal birth after cesarean section. Clin Obstet Gynecol 2001;44:604-8.  Back to cited text no. 20
    
21.
Al-Joborae IR, Ali A, Al-Joborae FF. Unexpected adverse medical and surgical health conditions in neonates after elective cesarean sections within the context of the influence of local socidemographic factors in Babylon. Medico Legal Update 2020;20:706-12.  Back to cited text no. 21
    
22.
Hallgrimsdottir H, Shumka L, Althaus C, Benoit C. Fear, risk, and the responsible choice: Risk narratives and lowering the rate of caesarean sections in high-income countries. AIMS Public Health 2017;4:615-32.  Back to cited text no. 22
    
23.
Machado LS. Cesarean section in morbidly obese parturients: Practical implications and complications. N Am J Med Sci 2012;4:13-8.  Back to cited text no. 23
    
24.
Feldman N, Skoll A, Sibai B. The incidence of significant fetomaternal hemorrhage in patients undergoing cesarean section. Am J Obstet Gynecol 1990;163:855-8.  Back to cited text no. 24
    
25.
Parliamentary Office of Science and Technology. Cesarean sections. Postnote 2002;184:1.  Back to cited text no. 25
    
26.
McNally OM, Turner MJ. Induction of labour after 1 previous Caesarean section. Aust N Z J Obstet Gynaecol 1999;39:425-9.  Back to cited text no. 26
    
27.
Familiari A, Neri C, Caruso A, Airoldi C, Barone-Adesi F, Zanconato G, et al. Vaginal birth after caesarean section: A multicentre study on prognostic factors and feasibility. Arch Gynecol Obstet 2020;301:509-15.  Back to cited text no. 27
    
28.
van der Spek L, Sanglier S, Mabeya HM, van den Akker T, Mertens PL, Houweling TA. Socioeconomic differences in caesarean section – Are they explained by medical need? An analysis of patient record data of a large Kenyan hospital. Int J Equity Health 2020;19:117.  Back to cited text no. 28
    
29.
Srinivasan T. Who Forced the C-Section? Maternal-Fetal Conflict and Different Objectives of Care. Penn Bioethics Journal. 2020;15.(Citation as provided by Google scholar).  Back to cited text no. 29
    



 
 
    Tables

  [Table 1], [Table 2], [Table 3], [Table 4], [Table 5], [Table 6]



 

Top
 
  Search
 
    Similar in PUBMED
   Search Pubmed for
   Search in Google Scholar for
 Related articles
    Access Statistics
    Email Alert *
    Add to My List *
* Registration required (free)  

 
  In this article
Abstract
Introduction
Materials and Me...
Results
Discussion
Conclusion
References
Article Tables

 Article Access Statistics
    Viewed1640    
    Printed77    
    Emailed0    
    PDF Downloaded177    
    Comments [Add]    

Recommend this journal