A Four-Year Review of Caesarean Section at a Secondary Healthcare

Facility in Abuja, Northcentral Nigeria

Alu Francis E1, Aghahowa Michael E2, Nwachukwu Chiemezie N.D3, Anate Abdullahi4,

Igbinovia Imuentinyan5, Hashim Abdullah Daula6

1.Consultant Obstetrician & Gynaecologist/Associate Professor, Department of Obstetrics and Gynaecology,

Asokoro District Hospital, Abuja and Nile University of Nigeria, Abuja; Email: drfrankalu@yahoo.com;

francis.alu@nileuniversity.edu.ng. 2. Consultant Surgeon/Senior Lecturer, Department of Surgery, Asokoro

District Hospital and Nile University of Nigeria, Abuja; Email: michael.ehienagudia@nileuniversity.edu.ng;

3.Consultant Obstetrician & Gynaecologist, Department of Obstetrics and Gynaecology, Maitama District

Hospital, Abuja; Email: nduum@yahoo.co.uk. 4. Consultant Obstetrician & Gynaecologist, Department of

Obstetrics & Gynaecology, Maitama District Hospital, Abuja. Email: abdullahianate@gmail.com. 5.Consultant

Obstetrician & Gynaecologist/Lecturer 1, Department of Obstetrics & Gynaecology, Maitama District Hospital,

Abuja and Baze University, Abuja; Email: tinyano@yahoo.com; 6. Senior Registrar, Department of Obstetrics

& Gynaecology, Asokoro District Hospital, Abuja. Email: dauly21@yahoo.com

Abstract

Correspondence

Dr. Francis E. Alu

Department of Obstetrics &

Gynaecology,

Asokoro District Hospital/Nile

University of Nigeria, Abuja

+2348037206243

drfrankalu@yahoo.com;

francis.alu@nileuniversity.edu.ng

Background: Caesarean section (CS) rates have been on the increase worldwide for

various reasons. Despite the global increase in rates, there still exist wide disparities in

rates between regions, countries and within countries. The indications for CS have

evolved to include non-medical indications such as maternal and obstetricians’

preferences, and for social reasons. Aim: The aim of the study was to determine the

rate, indications, outcomes and complications of CS in a secondary healthcare facility

in Abuja, Northcentral Nigeria. Materials and method: This was a retrospective study

of all cases of CS performed at Maitama District Hospital, Abuja between 1st January

2019 and 31st December 2022. The relevant data were extracted from the patients’

records in the hospital’s Electronic Medical Records database and also from the

delivery registers in the labour ward, and operating theatre records. Data analysis was

done using SPSS version 26. Results were presented in tables as frequencies and simple

percentages. Results: During the study period, there was a total of 6,438 deliveries,

with 2,800 CS, giving an overall CS rate of 43.5%. Emergency CS was the commonest

type (53.3%). The commonest indications for the CS were CPD (38.7%), fetal distress

(26.4%), and two or more previous CS (11.1%). Anaemia was the commonest maternal

postoperative complication accounting for 25.6% of cases. There were six maternal

deaths (0.2%). Majority (81%) of the babies had good Apgar scores with 14.9% having

various degrees of birth asphyxia. There were 106 perinatal deaths (4.1%). Conclusion:

The CS rate in this study is substantially higher than both the WHO recommended rates

and Nigeria national average. Indications were varied with contributions from CPD,

fetal distress, breech presentation, previous CS and maternal request worthy of note.

Maternal and perinatal outcomes were good, despite the high proportion of emergency

CS. Measures to improve access to antenatal care and labour management practices,

plus patient education, will help stem the rising CS rates.

Keywords: Caesarean section, indications, outcome, complications, Abuja

Alu, et al. Caesarean Section in Abuja

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

250

INTRODUCTION

Caesarean section (CS) is a common surgical

intervention in obstetrics practice. It refers to the delivery

of the fetus, placenta and membranes through an

abdominal and uterine incision after the age of fetal

viability. It is often performed for maternal or fetal

indications, or both.1 Caesarean section has become

increasingly common in both developed and developing

countries with wide variations between regions, countries

and within countries.2,3 The World Health Organization

(WHO) recommended a Caesarean section rate (CSR) of

between 10-15% with a declaration that there was no

justification for CSR to be higher than 10-15% in any

region of the world.2 However, available evidence

suggests that there is lack of consensus on what the

appropriate CSR should be worldwide.3

Globally, the CSR is rising due to many factors.

These include overdiagnosis of fetal distress due to the

advent of electronic fetal monitoring and increased

confidence in the general safety of caesarean section due

to better surgical techniques and anaesthesia, increasing

induction of labour, over-estimation of risk with labour

after a prior caesarean section, maternal and obstetrician

preferences.4,5

Currently, the global average is 21.1%, ranging

from 5% in sub-Saharan Africa to 42.8% in Latin

America and the Caribbean, and is projected to rise to

30% by 2030, with both unmet need and overuse

coexisting.4 While the national average for CSR in

Nigeria remains relatively low at 17.6%, hospital-based

data from tertiary and private facilities show higher rates.

Reported rates in Nigeria range between 5.8%-51.3%.6-18

The disparities in the rates, indications and complications

of CS in facilities across the geopolitical zones of Nigeria

are thought to be influenced by urban-rural differences,

socioeconomic factors and access to healthcare

services.17,18

Traditionally, CS has been classified according to the

indication as elective or emergency. The common

indications for CS include previous CS, malpresentation,

cephalopelvic disproportion (CPD)/obstructed labour, fetal

distress, antepartum haemorrhage, medical conditions in

pregnancy such as hypertensive disorders of pregnancy,

failed induction of labour and maternal request.1-5

CS is not without risks. It is associated with

complications to both mother and the baby. Recognised

complications include haemorrhage, intra-operative injury

to visceral organs, post-operative wound infection,

anaesthetic complications, neonatal respiratory morbidity,

increased maternal and perinatal mortality, anaemia, more

extended hospital stay, and compromise of the woman’s

obstetric career as a result of repeated CS.19

The aim of this study was to determine the rate,

indications and outcome of Caesarean section in a secondary

healthcare facility in Abuja, Northcentral Nigeria. The

specific objective was to audit the practice in our facility

and provide evidence-based institutional data, being the

first of its kind in the facility.

MATERIALS AND METHODS

This was a retrospective review of all cases of CS

performed at the maternity unit of Maitama District

Hospital (MDH), Abuja over a 4-year period, between 1st

January 2019 and 31st December 2022. MDH is one of

the public secondary level healthcare facilities in the

cosmopolitan city of Abuja. It is located in the Abuja

Municipal Area Council of the Federal Capital Territory

(FCT). It is accredited for residency training in Obstetrics

and Gynaecology, and serves as a referral centre for

patients from both public and private health institutions

in the FCT and its environs. The hospital operates an

electronic medical records system (E-MRS).

For the study, data were collected from the

patients’ records in the E-MRS database and also from

the delivery registers in the labour and postnatal wards,

and operating theatre records. The relevant

socio‑demographic and obstetric characteristics of the

patients obtained included: age, booking status, parity,

indication for the CS, and maternal and perinatal

complications and outcomes. Where more than one

indication for the CS was stated, the main indication was

taken for analysis. Similarly, only major maternal post-

operative complications were considered for analysis.

The data extracted were analysed using Statistical

Package for Social Sciences (SPSS) version 26 for

windows (SPSS 26, IBM Inc., Chicago, IL USA). The

results were presented in tables as frequencies and simple

percentages. Ethical approval for the study was obtained

from the Institution’s Research and Ethics Committee.

RESULTS

A total of 6,438 deliveries occurred during the period of

study. Out of these, 2,800 were caesarean sections, giving

a CS rate of 43.5%. Emergency CS accounted for 1,491

(53.3%) while elective CS accounted for 1,309 (46.7%).

Of the 2,800 CS cases, data on 256 cases were

incomplete; hence only 2,544 case records were available

for analysis (91% retrieval rate).

The general trend of CS over the study period

remained fairly constant (42.4% in 2019; 42.2% in 2020;

46.2% in 2021; 43.7% in 2022). The slightly higher CSR

(46.2%) in 2021 occurred during the first wave of

COVID-19 pandemic, when the facility served as the

only centre accepting referred cases.

Alu, et al. Caesarean Section in Abuja

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

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Table 1: Demographic characteristics of the study

participants

Table 2: Indications for caesarean section among the study

participants

Table 3: Maternal and Perinatal outcomes and complications

As shown in Table 1, most of the women,

1,182(46.5%), were within the age group 21-30years;

886(34.8%) in the 31-40years age group, (Age range:17-

42years). Majority, 1,508(59.3%), were booked. The

commonest parity was Primigravida, representing

1,067(41.9%) of the cases. Multigravida (para1-4)

accounted for 986(38.8%) and grandmultipara

491(19.3%).

Table 2 shows the various indications for CS

during the study period. Cephalopelvic disproportion

(CPD) was the commonest indication, accounting for

984(38.7%), followed by fetal distress, 672(26.4%), and

two or more previous CS, 282(11.1%.). Hypertensive

disorders of pregnancy (mainly severe

preeclampsia/eclampsia) accounted for 103(4.0%).

Failed VBAC and failed IOL accounted for 94(3.7%) and

54(2.1%) respectively. Malpresentation (due mainly to

breech presentation) accounted for 60(2.4%), while

maternal request accounted for 22(0.9%).

Table 3 shows maternal and perinatal outcomes

and complications. Anaemia was the commonest

maternal postoperative complication accounting for

25.6%, followed by PPH (12.1%), wound infection

(9.2%), and wound dehiscence (3.3%). There were six

maternal deaths (0.2%), giving a maternal mortality rate

of 236/100,000 caesarean births. Some of the women had

more than one complication. All the cases of PPH had

blood transfusion ranging from two to five units of blood.

Of the 2,606 neonates (including 58 twins and two

triplets) available for analysis, 2,112(81.0%) had normal

Apgar scores (>6) while 388(14.9%) had various degrees

of birth asphyxia. There were 106 perinatal deaths

(4.1%), giving a perinatal mortality rate of 41/1,000 total

births.

DISCUSSION

The caesarean section rate (CSR) of 43.5% in this study

is significantly higher than the WHO recommended rates

of 10-15% and most rates in Nigeria.6,9,10,11,13 It is,

however, comparable to the 43.8% reported by Maduka

et al in Agbor,12and 42.4% by Allagoa et al in Yenogoa,7

both in Nigeria, and the 42.2% reported in Latin America

and the Caribbeans.8 A rate of 21.4% was reported by

Isah et al8 in a tertiary hospital located in a rural part of

Abuja, within the same city where our study was

conducted. A very high CSR of 51.3%, comparable to

rates recorded in Egypt, Cyprus and Brazil, was reported

by Babah et al in a teaching hospital in Lagos, Nigeria.16

This disparity in rates could be attributed to the

differences in the study design, the patients’ demographic

characteristics, type of health facility, and institutional

protocols among others. Higher rates are common in

tertiary and regional facilities like ours, that manage

complicated and referred high-risk cases.18

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The policy of use of CS for breech in

primigravidae, the restriction on the use of induction and

augmentation of labour (IOL/AOL) for VBAC cases,

and the lack of routine practice of ECV for breech

presentation in our facility, are possible contributory

factors to the high CS rate recorded in the study.20 For

instance, in our facility, CS is the only option for delivery

in patients with one previous CS who fail to go into

spontaneous labour at term, or who fail to progress in

labour due to inefficient uterine action, where IOL/AOL

could have been employed.

A National survey on caesarean section and

associated factors in Nigeria by Adewuyi et al reported

an overall prevalence of CS in Nigeria to be 2.7% with

5.2% in urban and 1.2% in rural areas, indicating unmet

needs in use of CS, despite the reported high institutional-

based rates.18 The lower rates of CS reported in rural

areas compared to urban areas are attributable to lack of

access to health care facilities, low acceptance of CS

among women due to fear of complications, negative

perception of CS as an abnormal mode of delivery, and

high cost of the surgery.17,18,21 There is, thus, a concurrent

overuse and underuse of CS in Nigeria.17

The vast majority of the women in the study were

primigravida (41.9%) and in the age group 21-30years

(46.5%). This observation is in consonance with findings

in other studies.6,8,12,13 Primigravidae are known to be

prone to dysfunctional labours, including prolonged and

obstructed labour (due to CPD), which are most often

associated with fetal distress requiring operative

interventions.22 A high rate of CPD and fetal distress was

also observed in this category of parturients in our study.

Ugwu et al, however, reported a higher proportion of CS

(51.4%) in multigravida (para 1-4) compared with

primigravida (41.5%) in Enugu.9 A lower rate of 7.1%

was, however, recorded in grandmultipara in their study

and they attributed their findings of higher CSR in

women of low parity compared to grandmultiparous

women to the fact that labour tends to be smoother and

faster in multiparous women compared with

primigravida. There were more booked (59.3%) than

unbooked (40.7%) women in this study, reflecting the

cosmopolitan nature of Abuja and our population of study

which comprised mostly educated civil servants.

Emergency CS was the commonest type of CS

noted in this study (53.3%). Several other studies

reported similar findings.6-11Majority of these emergency

CS were performed in the unbooked, and referred

patients. Maduka et al, however, reported a higher

proportion of elective CS (52.9%) in their study in a

secondary health facility.12

The indications for CS in this study were many

and varied. The commonest indication was CPD (38.7%),

followed by fetal distress (26.4%), and two or more

previous CS (11.1%). Similar findings were reported in

other studies.7,8This is not surprising as CPD and fetal

distress are common features in primigravidae who

accounted for majority of the cases. Failed VBAC,

ending in emergency CS, accounted for 3.7% of the

indications. This, with the contribution from two or more

previous CS (11.1%) accounted for a significant 14.8%

of the indications for CS in this study.

It is also worthy of note that maternal request

accounted for nearly 1% of indications in this study. The

reasons for maternal request for CS in our study included

concerns about fetal wellbeing and uterine rupture during

trial of vaginal birth after a previous CS (VBAC),

intolerable pain and fear of uterine rupture during

induction of labour, advanced maternal age, history of

prolonged infertility, previous traumatic experience

during vaginal delivery, and desire to have a baby on a

specific day and/or date. Chigbu et al reported a

prevalence of CS on request of 4.4% in their study, citing

previous infertility and advanced maternal age at first

pregnancy as the common reasons for the request.5

Several other studies have reported on the implications of

non-medically related maternal request for CS on the

health of the mother and baby, and on increasing CSR.5,23

Although CS can be a life-saving intervention for

both mother and baby, it is also associated with short-and

long-term complications including higher risk of

maternal and perinatal morbidity and mortality.19 Our

study showed that the commonest post-operative

maternal complication was anaemia, which was in

tandem with the findings by Isah et al in Abuja,8 Ugwu et

al in Enugu9 and John et al in Portharcourt.13 Other

maternal complications recorded in this study include

postpartum haemorrhage (PPH), wound infection, and

wound dehiscence. All of the women with PPH received

blood transfusions.

There were six maternal deaths (0.2%), giving a

maternal mortality rate (MMR) of 236/100,000 caesarean

births. All of the maternal deaths occurred in emergency

CS cases, and all were unbooked referred cases, most of

whom arrived the facility in moribund state. Three of the

maternal deaths occurred in patients with eclampsia, two

following PPH, and the remaining one from sepsis

following prolonged obstructed labour.The maternal

mortality rate observed in this study is low compared to

the rates of 0.7% (MMR 700/100,000) and 0.8% (MMR

800/100,000) reported by Isah et al8 and Ugwu et al, 9

respectively.

Majority of the babies delivered within the study

period had good Apgar scores (81%) while 14.9% had

various degrees of birth asphyxia, with more than half of

these being delivered by emergency CS. There were 106

perinatal deaths (4.1%), giving a perinatal mortality rate

of 41/1,000 total births. This finding is comparable to the

rates reported in other studies.8,24,25

Alu, et al. Caesarean Section in Abuja

Tropical Journal of Obstetrics and Gynaecology (TJOG) Vol. 43 No. 4 (2025)/Published by Journalgurus

253

A cursory look at the various indications for CS in

this study shows that patient education, improved access

to antenatal care, promotion of VBAC, ECV and assisted

vaginal breech delivery practices, optimising IOL and

consistent management of labour with partograph, will

help in reducing the rising CS rate.

CONCLUSION

Our CS rate of 43.5% is substantially higher than both the

WHO recommended rates and Nigeria national average.

Indications were varied with contributions from CPD,

fetal distress, breech presentation, previous CS and

maternal request worthy of note. Both maternal and fetal

outcomes were relatively good despite the high

proportion of emergency CS.

Limitation of the study

This is related to its retrospective design with its

recognised drawbacks including loss of data. The

indications for CS were multiple in some cases

necessitating the selection of only the one considered as

the main indication. The diagnosis of fetal distress was

clinical and not supported with fetal scalp sampling for

pH studies.

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