E-ISSN:2455-5444
P-ISSN:2581-4389
RNI:MPENG/2017/74037

Research Article

Caesarean section

Obs Gyne Review - Journal of Obstetric and Gynecology

2021 Volume 7 Number 6 November December
Publisherwww.medresearch.in

Rate and Indications of Caesarean section in the Apollo Institute of Medical Sciences and Research, Chittoor: A retrospective study

Shwetha N.1, Harish K.2*, Reddy E.3, Kedar Karthik C.4, Pujith Kumar G.5, Sai Chandhan T.6
DOI: https://doi.org/10.17511/joog.2021.i06.02

1 N Shwetha, Associate Professor, Dept of OBG, Sri Lakshminarayana Institute of Medical Sciences, Pondicherry, Union Territory, India.

2* KM Harish, Associate Professor, Dept of OBG, The Apollo Institute of Medical Sciences and Research, Chittoor, Andhra Pradesh, India.

3 E.Mallikarjuna Reddy, Housesurgeon, Dept of OBG, The Apollo Institute of Medical Sciences and Research, Chittoor, Andhra Pradesh, India.

4 Ch Kedar Karthik, Housesurgeon, Dept of OBG, The Apollo Institute of Medical Sciences and Research, Chittoor, Andhra Pradesh, India.

5 G Pujith Kumar, Housesurgeon, Dept of OBG, The Apollo Institute of Medical Sciences and Research, Chittoor, Andhra Pradesh, India.

6 T Sai Chandhan, Housesurgeon, Dept of OBG, The Apollo Institute of Medical Sciences and Research, Chittoor, Andhra Pradesh, India.

Aim: To determine the rate and indications of caesarean section. Method: A retrospective study was conducted at The Apollo Institute Of Medical Sciences And Research, Chittoor, for one year. The data was retrieved from the medical record of the operation theatre. Results: During the study period, 34.85% (1,432 out of 4109) of women underwent caesarean section. The majority of the women (80.02%) belonged to 20-30 years, and 69.13% had studied up to metric. The majority of women, 78.35 %, were from a rural area, and 87.70 % belonged to middle socioeconomic status. Booked cases were 94.55%, and multigravida (54.53%) were the majority to undergo a caesarean section. The four leading indications were previous caesarean section (40.22%), fetal distress (17.94%), non-progress of labour (13.40%) and Oligo-Hydramnious (7.89%). Conclusions: The rate of caesarean section is more than the national (India) and global caesarean section rate. Previous caesarean section is the main indication followed by fetal distress.

Keywords: Caesarean section, Fetal distress, Non progress of labour

Corresponding Author How to Cite this Article To Browse
KM Harish, Associate Professor, Dept of OBG, The Apollo Institute of Medical Sciences and Research, Chittoor, Andhra Pradesh, India.
Email: 		N Shwetha, KM Harish, E.Mallikarjuna Reddy, Ch Kedar Karthik, G Pujith Kumar, T Sai Chandhan, Rate and Indications of Caesarean section in the Apollo Institute of Medical Sciences and Research, Chittoor: A retrospective study. Obs Gyne Review J Obstet Gynecol. 2021;7(6):64-70.
Available From
https://obstetrics.medresearch.in/index.php/joog/article/view/147

Manuscript Received Review Round 1 Review Round 2 Review Round 3 Accepted
2021-11-30 2021-12-01 2021-12-08 2021-12-15 2021-12-22
Conflict of Interest Funding Ethical Approval Plagiarism X-checker Note
Nil Nil Yes 19%

© 2021by N Shwetha, KM Harish, E.Mallikarjuna Reddy, Ch Kedar Karthik, G Pujith Kumar, T Sai Chandhanand Published by Siddharth Health Research and Social Welfare Society. This is an Open Access article licensed under a Creative Commons Attribution 4.0 International License https://creativecommons.org/licenses/by/4.0/ unported [CC BY 4.0].

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Introduction

Childbirth is a profound and powerful human experience. Women's birth accounts often describe feelings of empowerment, elation and achievement, particularly following vaginal birth without medical interventions. The other mode of delivery is by operation, which has become more common in recent years. This operation is termed' caesarean section', which refers to delivering a baby through incisions made in the mother's abdominal wall and uterus.[1,2].

Caesarean delivery is a life-saving obstetric surgical intervention for mothers and babies. The rate of caesarean delivery has considerably increased globally during the last few decades. India is not an exception. However, during the last decade, the increase in caesarean section deliveries has become a serious concern for public health experts globally.[3].

The Southern Indian states have recorded substantially higher levels of caesarean deliveries in comparison to the other parts of the country. The highest caesarean delivery rate was observed in Telengana (60%), followed by Andhra Pradesh (42%) in India. Studies have indicated that geographical region and socio-demographic factors significantly influence caesarean delivery in India.[4]. However, the national figure for caesarean births in a heterogeneous country such as India does not adequately reflect the diversity of the public health situations and challenges. The present study investigates the rate of caesarean section, socio-demographic factors influencing caesarean section and indications contributing to caesarean section.

Material and Methods

Duration and type of study: Present study is a retrospective study for one year from 1st January 2020 to 31st December 2020.

Setting: hospital setting in the Department of Obstetrics and Gynecology, The Apollo Institute of Medical Sciences and Govt District Hospital, Chittoor, a large tertiary care hospital in southern Andhra Pradesh of India.

Sampling methods: Women who underwent caesarean section and their details documented in the caesarean section register kept in the operation theatre.

Inclusion criteria: All the patients delivered by caesarean section during the study period were included in the study.

Exclusion criteria: women who underwent vaginal delivery.

Data collection procedure: Data of the caesarean section as per the operation theatre list were collected in a retrospective manner from the caesarean section register. Data were collected on a predesigned proforma, which included socio-demographic characters & indications for caesarean section.

Ethical consideration & permission: Not required as it is a retrospective study.

Statistical Analysis: Caesarean section rate is calculated and is defined as the percentage of births achieved by Caesarean section among a total number of live births in the study period. Frequencies and percentages were calculated for Age, Education, Residence, Socioeconomic status, Gravida, Booked or unbooked, and Indications of Caesarean Section.

Results

Table 1 shows that among 4109 total live births, 2677 women underwent vaginal delivery, and 1432 underwent caesarean section. The caesarean delivery rate was 34.85%. Table 4 provides the socio-demographic and obstetric characteristics of the study participants. Age distribution showed that the majority of the women who underwent caesarean section was in the age group of 20–30 years. Elderly women were 11.31%, and teenage pregnancy was 8.65%. Patients' educational status shows that 69.13% had studied up to metric were as 29.88% had graduation and 0.97% didn't have any formal education. Women from the rural area were 78.35% and from the urban area was 21.64%. Socioeconomic status of patients shows that women of Middle socioeconomic status were 87.70%, were as women of lower and upper socioeconomic status were 9.77% and 2.51%, respectively. Multigravidas were 54.53% and Primigravida were 45.46%. Booked patients were 94.55%, and Unbooked patients were 5.44%. Table 5 presents that four leading indications were: previous caesarean section (40.22%), fetal distress (17.94%), non-progress of labour (13.40%) and Oligo-Hydramnious (7.89%).


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Table 1: Caesarean Section rate. 

  Vaginal deliveries Caesarean Section Total deliveries
Number 2677 1432 4109
Percentage 65.15% 34.85% 100%

Table 2: Caesarean Section rate worldwide and in different regions [6]. 

S. no Regions CS rate CS rate world wide
1 Africa 9.2 21.1%
2 Oceania 21.4%
3 Asia 23.1
4 Europe 25.7%
5 America 39.3%

Table 3: Caesarean Section rate in India and other five countries with highest and lowest CS rate [6]. 

The top five countries with the highest CS rate worldwide
S.no Country CS rate
1 Brazil 55.7%
2 Cyprus 55.3%
3 Egypt 51.8%
4 Turkey 50.8%
5 Romania 46.9%
6 INDIA 17.2%
The top five countries with the lowest CS rate worldwide
S. no Country CS rate
1 Cameroon 2.4%
2 Madagascar 2%
3 Ethiopia 1.9%
4 Niger 1.4%
5 Chad 1.4%

Table 4: Socio-demographic Factors

S. no Socio-Demographic character Total CS
number percentage
1 Age Tenage 124 8.65 %
20 to 30 years 1146 80.02 %
Elderly (above 30yrs) 162 11.31 %
2 Education No literacy 14 0.97 %
Matric 990 69.13 %
Graduate 428 29.88 %
3 Residence Rural 1122 78.35 %
Urban 310 21.64 %
4 Socioeconomic status Lower 140 9.77 %
Middle 1256 87.70 %
Upper 36 2.51 %
5 Gravida Primagravida 651 45.46 %
Multigravida 781 54.53 %
6 Booking status Unbooked 78 5.44 %
Booked 1354 94.55 %

The less common indication was Cephalo-pelvic disproportion (6.21%), Malpresentation (5.79%), chronic health conditions (3.91%) and Failed Induction (1.88%). Other least common indications were Placental disorders (0.69%), Obstructed labour (0.62%), multiple pregnancy (0.48%), Short stature in labour (0.48%) and Precious pregnancy (0.4%).

Table 5: Indication for Caesarean Section 

S. no Indications For CS Total CS
number %
1 Previous caesarean 576 40.22 %
2 Fetal distress 257 17.94 %
3 Non-Progress of labour 192 13.40 %
4 Oligo-Hydramnious 113 7.89 %
5 Cephalo-pelvic disproportion 89 6.21 %
6 Malpresentation 83 5.79 %
7 Chronic health conditions 56 3.91 %
8 Failed Induction 27 1.88 %
9 Placental disorders 10 0.69 %
10 Obstructed labour 9 0.62 %
11 Multiple pregnancies 7 0.48 %
12 Short stature in labour 7 0.48 %
13 Precious pregnancy 6 0.41%
TOTAL 1432 100%

Discussion

The caesarean delivery rate and the indications of caesarean delivery were examined during the study period. A total of 4109 live births occurred in the hospital in 2020. The caesarean delivery rate was 34.85% in the present study. In India, Telangana state has the highest C-section rate of 57.7%, followed by Andhra Pradesh state with 40.1%. Caesarean Section rate in India is 17.2% (NFHS-IV) during 2015-16.[4]. Caesarean section rate in the present study (34.85%) is lower than the state (Andhra Pradesh with 40.1%) statistics but higher than the national (India with 17.2%) statistics. CS rate in the present study was almost similar (34.1%) to the study of Banerjee A et al. conducted on a population of Silchar in Assam.[5].

The global CS rate was 21.1%, with an average of 24.2% in the less developed region. Present study CS rate is higher when compared to Africa, Oceania, Asia and European region CS rate as well as the global CS rate, but lesser when compared to American region CS rate.  The top five countries with the highest CS rate worldwide


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were: Dominican Republic (58.1%), Brazil (55.7%), Cyprus (55.3%), Egypt (51.8%) and Turkey (50.8%), which also represented the highest CS rate in Americas, Asia, and Africa. In Europe, the highest CS rate was found in Romania (46.9%). The five countries with the lowest CS rate around the world belong to Africa: Chad (1.4%), Niger (1.4%), Ethiopia (1.9%), Madagascar (2%) and Cameroon (2.4%).[6]. Present study CS rate and Indian CS rate is relatively higher when compared to Cameroon, which has the highest CS among the top five countries with the lowest CS rate around the world, and considerably lower when compared to Romania, which has the lowest CS among top five countries with the highest CS rate around the world

In the present study, it is observed that younger (30 years and below) women (80.02%) were more likely to have a CS birth. Similar results were seen in Banerjee A et al. [5] and Kaur J et al. [7], while studies by Begum T et al. [8] and Rebelo F et al. [9] observed a higher likelihood for CS delivery among older women. Educational attainment of women was found to be positively associated with C-section delivery in which women with metric (69.13%) or higher education (29.88%) were more likely to have caesarean delivery compared with uneducated women. Similar results were seen in Kathuria B et al. [4], which states that in India, the percentage of C-section rate is very high among women having secondary and higher education. In contrary to present study, Apanga PA et al [10]. in their study, with a smaller sample size at northern Ghana reported a lower risk of CS delivery among women with secondary or higher education

The majority of women (78.35%) in the present study were from rural areas. Similar results were seen in Banerjee A et al. [5] but are contrary to the present study, bi-variate analysis by Kathuria B et al. [4] reveals that the rate of C-section in urban areas is more than double than in rural areas in India. Even though this disparity between rural and urban areas in India is minimum in the Southern region, the C-section rate even in rural areas (33.6%) is more than doubled than the recommended rate of 15% by WHO. Middle socioeconomic status women (87.70%) were the majority to undergo a caesarean section. A similar result was seen in the study of Divyamol N et al. [11]. The present study's finding of the higher likelihood of CS delivery among middle and lower socioeconomic status women could be

the result of the costs associated with CS birth, and the Institute in which the present study was conducted is a government health care facility where caesarean/vaginal delivery is covered under free maternal health services policy.

Contrary to the present study, Kathuria B et al. [4] states that in India percentage of C-section rate are very high among women belonging to the rich wealth quintile. Similar results were seen in the study of Ahmmed F et al. [12]. In Bangladesh, where the rich mothers showed the highest rate of CS delivery (41%), followed by middle (19.90%) and poor mothers (8.70%). Even though a study by Kathuria B et al. [4] and Ahmmed F et al. [12] states that CS is common in the rich wealth quintile, the high socioeconomic status women were significantly less in the present study because the majority of them choose private health facility and only a few of them who are in emergency land up in public health care facility.

The percentage of multigravida (54.53%) women was higher to undergo a caesarean section. Similar results were seen in the study of Reddy KM et al. [13], in which these results were explained due to the domino effect of the caesarean section. As the rates of caesarean section increase, more women will be multigravida and need repeat caesarean section. Contrary to the present study, Dankwah E et al. [14] states that the CS rate decreases as the birth order increases. In the present study, booked patients were 94.55%. A similar result was seen in the study of Shrestha DB et al. [15]. In which 94.2% were booked. In the analysis of NFHS-4 conducted by Kathuria B et al. [4], women who received four or more ANC visits were more likely to have a caesarean birth than women who did not receive ANC service. This is in contrast to the findings of Tebeu PM et al. [16] in Cameroon, who found no association between ANC attendance and CS.

In the present study, the most significant contributor to the rise in Caesarean Section rate is the previous caesarean section (40.22%) followed by fetal distress (17.94%), which is consistent with the findings of the study conducted by Begum T et al. [8] on Bangladesh population, Chavda D et al. [17] in the western part of India and Reddy KM et al. [13] in southern India. But in the studies by Banerjee A et al. [5], Shrestha DB et al. [15] and Yadav S et al. [18], fetal distress was the


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most common indication followed by previous caesarean section. The reason for increased previous caesarean cases in the present study may be because the current study institute is a large tertiary care centre catering for the whole district in which many deliveries are conducted. More referrals from peripheral health centres with less number trained personnel for monitoring labour discourages obstetricians from considering vaginal birth after caesarean. Other reasons are women refusing consent for the trial of labour after caesarean (TOLAC) and details regarding previous CS being not available. The higher rate of fetal distress and a second most common indication for caesarean section in the present study is due to only the cardiotocography-incorporated feto-maternal monitoring in diagnosing fetal distress.

Non-progress of labour (13.40%) was the third most common indication in the present study and the study of Begum T et al. [8]. It was the second most common indication in the study of Divyamol N et al. [11] and the least common indication in Chavda D et al. [17]. Adolescent pregnancies due to immaturity of their pelvis are at increased risk of more prolonged labour, and caesarean delivery is indicated for failure to progress or descent [19]. Teenage pregnancy of 8.65% in the present study may be the main reason for non-progress of labour in the present study. Monitoring labour by plotting a simple graph such as a partograph can reduce the CS rate for non-progress of labour. Oligohydramnios was the fourth most common indication at 7.89%. It is the least common indication in the study of Divyamol N et al. [11]. The survey by Ethiraj G et al. [20] stated a high possibility of emergency CS in the case of oligohydramnios.

Cephalo-pelvic disproportion (6.21%) is the fifth most common indication in the present study and Chavda D et al. [17]. CPD was most common in the study of Gurung RT et al. [21] and the least common indication in the study of Divyamol N et al. [11]. CPD is common in nulliparous women and the most common indication for primary caesarean delivery [22]. Even though the primigravida percentage is 45.46% in the present study, CPD is only 6.21% which is significantly less. Malpresentation (5.79%) was the sixth commonest indication. Malpresentation was seen in 7% of patients who underwent caesarean section in the study of Gurung RT et al. [21], which is slightly more than the present study. Malpresentation

includes breech presentation, transverse lie and compound presentation. Multigravida patients are the majority in the present study which is a risk factor for breech presentation and transverse lie. Malpresentation was the third most common in the study of Reddy KM et al. [13]. and least common in the study of Gupta M et al. [24]. Chronic health conditions (3.91%) were the seventh common indication for caesarean section. This is slightly more than that reported by Reddy KM et al. [13], which showed an increase in the caesarean section for maternal indications like uncontrolled hypertension, pre-eclampsia, eclampsia and gestational diabetes mellitus to 2.99% in 2017-2018. Failed Induction (1.88%) was the eighth common indication. A similar percentage of failed Induction was seen in the study of Reddy KM et al. [13]. At 1.61% Significantly higher rate was seen in the study of Shrestha DB et al. [15] at 10% when compared to the present study.

The least common indications in the present study are Placental disorders (0.69%), obstructed labour (0.62%). The reported incidence of Placental diseases is as high as 1 per every 533 deliveries, mainly attributed to the increase in caesarean deliveries [25]. The incidence of MAP in the present study is 1 per every 410 deliveries, which is significantly less. Less percentage of obstructed labour (0.62%) is seen in the present study compared to that of Ayenew AA et al. [26]. In which the pooled incidence of obstructed labour in Ethiopia was 12.93%. The possible reason might be the least teenage pregnancy, fewer women with low socioeconomic status, and good ANC follow up in the present study. Other least common indications for caesarean section in the present study are multiple pregnancies (0.48%), Short stature in labour (0.48%) and Precious pregnancy (0.41%).

Conclusion

The rate of caesarean section is more than the national (India) and global caesarean section rate. Women of 20 to 30 years old with education up to metric, residing in a rural area with three or more ANC visits and belong to middle socioeconomic status are the majority to undergo a caesarean section. Previous caesarean section and fetal distress are the two significant indications for caesarean section.

What this study adds to existing knowledge:


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Still, previous caesarean sections and fetal distress continue to be the leading indications for caesarean section.

Abbreviations: CS: Caesarean sections. CPD: Cephalopelvic Disproportion. ANC: Antenatal Care.

Acknowledgements: We would like to thank the Principal, Medical Superintendent, and Head of the Department of OBG, The Apollo Medical College, Chittoor, for their support in the process of preparing this article.

Availability of data and materials: The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Authors' contributions: Harish KM and Shwetha N designed the study, analyzing data and writing the manuscript. MallikarjunaReddy E, KedarKarthik Ch, Pujith Kumar G and SaiChandhan T contributed to data collection and revised the manuscript. All authors read and approved the final manuscript.

Reference

01. Gaskin, Ina May. Ina May's guide to childbirth. Bantam, 2003. [Crossref][PubMed][Google Scholar]

02. Neilson JP. Interventions for suspected placenta praevia. Cochrane Database Syst Rev. 2003;(2):CD001998. doi: 10.1002/14651858.CD001998 [Crossref][PubMed][Google Scholar]

03. Essendi H, Mills S, Fotso JC. Barriers to formal emergency obstetric care services' utilization. J Urban Health. 2011 Jun;88 Suppl 2(Suppl 2):S356-69. doi: 10.1007/s11524-010-9481-1 [Crossref][PubMed][Google Scholar]

04. Kathuria, Bhawna, and Sherin Raj TP. "Regional Disparities and Determinants of Caesarean Deliveries in India. " Indian Journal of Youth and Adolescent Health (E-ISSN: 2349-2880) 7. 4 (2020): 15-23. [Crossref][PubMed][Google Scholar]

05. Banerjee, Alaka, Banasree Bhadra, and Kiriti R. Dey. Analysis of caesarean section in a tertiary care hospital, Assam, India. International Journal of Reproduction, Contraception, Obstetrics and Gynecology 7. 4 (2018): 1514-1518 [Crossref][PubMed][Google Scholar]

06. Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates:

global and regional estimates. BMJ Glob Health. 2021 Jun;6(6):e005671. doi: 10.1136/bmjgh-2021-005671 [Crossref][PubMed][Google Scholar]

07. Kaur, Jaspinder, Sargun Singh, and Kawaljit Kaur. Current trend of caesarean sections and vaginal births. Adv Appl Sci Res 4. 4 (2013): 196-202. [Crossref][PubMed][Google Scholar]

08. Begum T, Rahman A, Nababan H, Hoque DME, Khan AF, Ali T, et al. Indications and determinants of caesarean section delivery: Evidence from a population-based study in Matlab, Bangladesh. PLoS One. 2017 Nov 20;12(11):e0188074. doi: 10.1371/journal.pone.0188074 [Crossref][PubMed][Google Scholar]

09. Rebelo F, da Rocha CM, Cortes TR, Dutra CL, Kac G. High cesarean prevalence in a national population-based study in Brazil: the role of private practice. Acta Obstet Gynecol Scand. 2010 Jul;89(7):903-8. doi: 10.3109/00016349.2010.484044 [Crossref][PubMed][Google Scholar]

10. Apanga, Paschal Awingura, and John Koku Awoonor-Williams. Predictors of caesarean section in northern Ghana: a case-control study. Pan African Medical Journal 29. 1 (2018): 1-11. [Crossref][PubMed][Google Scholar]

11. Divyamol, N. , Lucy Raphael, and Nileena Koshy. Caesarean section rate and its determinants in a rural area of South India. Int J Community Med Public Health 3. 10 (2016) [Crossref][PubMed][Google Scholar]

12. Ahmmed F, Manik MMR, Hossain MJ. Caesarian section (CS) delivery in Bangladesh: A nationally representative cross-sectional study. PLoS One. 2021 Jul 15;16(7):e0254777. doi: 10.1371/journal.pone.0254777 [Crossref][PubMed][Google Scholar]

13. Reddy, Ke Manga, et al. "Prevalence and determinants of caesarean section in a rural tertiary teaching hospital: a 6-year retrospective study. " Int J Reproduction, Contraception, Obstet Gynecol 8. 2 (2019): 560. [Crossref][PubMed][Google Scholar]

14. Dankwah E, Kirychuk S, Zeng W, Feng C, Farag M. Socioeconomic inequalities in the use of caesarean section delivery in Ghana: a cross-sectional study using nationally representative data. Int J Equity Health. 2019 25th October;18(1):162.


Obs Gyne Review - Journal of Obstetric and Gynecology 2021;7(6)69
Shwetha N et al: Rate and Indications of Caesarean section in AIMS

doi: 10.1186/s12939-019-1063-6 [Crossref][PubMed][Google Scholar]

15. Shrestha DB, Khatri R, Oli PR, Malla R, Shrestha C, Khatiwada R, et al. Cesarean Section in a Maternity Unit of a Tertiary Care Center of Nepal: A Descriptive Cross-sectional Study. JNMA J Nepal Med Assoc. 2021 Apr 30;59(236):322-326. doi: 10.31729/jnma.5150 [Crossref][PubMed][Google Scholar]

16. Tebeu PM, Mboudou E, Halle G, Kongnyuy E, Nkwabong E, Fomulu JN. Risk factors of delivery by caesarean section in cameroon (2003-2004): a regional hospital report. ISRN Obstet Gynecol. 2011;2011:791319. doi: 10.5402/2011/791319 [Crossref][PubMed][Google Scholar]

17. Chavda, Dolly, Kamal Goswam, and Kavita Dudhrejiya. A cross sectional study of 1000 lower segment cesarean section in obstetrics and gynecology department of PDU Medical College, Rajkot, Gujarat, India. International Journal of Reproduction, Contraception, Obstetrics and Gynecology 6. 4 (2017): 1186-1192. [Crossref][PubMed][Google Scholar]

18. Yadav, Shweta, et al. Analysis of caesarean rate, indications and complications: review from medical college Ambala, Haryana, India. International Journal of Reproduction, Contraception, Obstetrics and Gynecology 5. 10 (2016): 3326-3330. [Crossref][PubMed][Google Scholar]

19. Ganchimeg T, Ota E, Morisaki N, Laopaiboon M, Lumbiganon P, Zhang J, et al. WHO Multicountry Survey on Maternal Newborn Health Research Network. Pregnancy and childbirth outcomes among adolescent mothers: a World Health Organization multicountry study. BJOG. 2014 Mar;121 Suppl 1:40-8. doi: 10.1111/1471-0528.12630 [Crossref][PubMed][Google Scholar]

20. Ethiraj, Gomathy, Aditi C. Ramachandra, and Sandhya Rajan. Induction of Labor and Risk for Emergency Cesarean Section in Women at Term Pregnancy. Journal of Clinical Gynecology and Obstetrics 8. 1 (2019): 17-20 [Crossref][PubMed][Google Scholar]

21. Gurung, Rubina Tamrakar, et al. Prevalence and Outcome of Cesarean Section at Gandaki Medical College Teaching Hospital and Research Centre, Pokhara, Nepal. Journal of Gandaki

Medical College-Nepal 9. 2 (2016): 1-6. [Crossref][PubMed][Google Scholar]

22. Nicholson JM, Kellar LC. The active management of impending cephalopelvic disproportion in nulliparous women at term: a case series. J Pregnancy. 2010;2010:708615. doi: 10.1155/2010/708615 [Crossref][PubMed][Google Scholar]

23. Manjulatha, B. , and T. P. Sravanthi. Caesarean section rates in a Teaching Hospital: a ten year review. A Ten Year Review 14.8 (2015): 1-5 [Crossref][PubMed][Google Scholar]

24. Gupta, Meeta, and Vineeta Garg. The rate and indications of caesarean section in a tertiary care hospital at Jaipur, India. International Journal of Reproduction, Contraception, Obstetrics and Gynecology 6. 5 (2017): 1786-1793. [Crossref][PubMed][Google Scholar]

25. Bauer ST, Bonanno C. Abnormal placentation. Semin Perinatol. 2009 Apr;33(2):88-96. doi: 10.1053/j.semperi.2008.12.003 [Crossref][PubMed][Google Scholar]

26. Ayenew AA. Incidence, causes, and maternofetal outcomes of obstructed labor in Ethiopia: systematic review and meta-analysis. Reprod Health. 2021 10th March;18(1):61. doi: 10.1186/s12978-021-01103-0 [Crossref][PubMed][Google Scholar]


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