caesarean section incidence factors Kenya hospital

factors rising caesarean section Garissa Provincial General Hospital Kenya

caesarean section indications rising rates sub-Saharan Africa

PMID: 32641057

PMID: 30322584

https://panafrican-med-journal.com/content/series/28/1/7/ful…

PMID: 11684214

caesarean section determinants previous scar fetal distress East Africa

caesarean section rates trends Africa factors associated

PMID: 40190504

PMID: 32345146

PMID: 35578320

caesarean section rates Kenya KDHS demographic health survey trends 2022

ls -la /home/daytona/workspace/ 2>/dev/null && mkdir -p /home/daytona/workspace/…

~/garissa-cs-proposal/build_proposal.py

#!/usr/bin/env python3
"""
Research Proposal PDF generator using ReportLab
Title: Factors Associated with the Rising Incidence of Caesarean Section Deliveries
       at Garissa Provincial General Hospital, Kenya
Author: ABDINASIR ALI | Reg: D/CM/24017/862
"""

from reportlab.lib.pagesizes import A4
from reportlab.lib.styles import getSampleStyleSheet, ParagraphStyle
from reportlab.lib.units import cm
from reportlab.lib import colors
from reportlab.platypus import (
    SimpleDocTemplate, Paragraph, Spacer, Table, TableStyle,
    HRFlowable, PageBreak, ListFlowable, ListItem, KeepTogether
)
from reportlab.lib.enums import TA_CENTER, TA_LEFT, TA_JUSTIFY
from reportlab.pdfbase import pdfmetrics

OUTPUT = "/home/daytona/workspace/garissa-cs-proposal/CS_Research_Proposal_Garissa.pdf"

# ── Colour palette ──────────────────────────────────────────────────────────
DARK_BLUE  = colors.HexColor("#003366")
MID_BLUE   = colors.HexColor("#005599")
LIGHT_BLUE = colors.HexColor("#cce0f5")
GOLD       = colors.HexColor("#c8a400")
WHITE      = colors.white
GREY       = colors.HexColor("#555555")
LIGHT_GREY = colors.HexColor("#f4f4f4")

# ── Document setup ───────────────────────────────────────────────────────────
doc = SimpleDocTemplate(
    OUTPUT,
    pagesize=A4,
    leftMargin=3*cm, rightMargin=2.5*cm,
    topMargin=2.5*cm, bottomMargin=2.5*cm,
    title="Research Proposal – Caesarean Section at Garissa PGH",
    author="Abdinasir Ali",
    subject="Factors Associated with Rising CS Incidence at Garissa PGH, Kenya",
)

styles = getSampleStyleSheet()

# ── Custom paragraph styles ──────────────────────────────────────────────────
def make_style(name, parent="Normal", **kw):
    s = ParagraphStyle(name, parent=styles[parent], **kw)
    return s

title_style = make_style("ProposalTitle", "Normal",
    fontSize=18, leading=24, textColor=DARK_BLUE,
    alignment=TA_CENTER, spaceAfter=6, fontName="Helvetica-Bold")

subtitle_style = make_style("ProposalSubtitle", "Normal",
    fontSize=13, leading=18, textColor=MID_BLUE,
    alignment=TA_CENTER, spaceAfter=4, fontName="Helvetica-Bold")

meta_style = make_style("Meta", "Normal",
    fontSize=10, leading=14, textColor=GREY,
    alignment=TA_CENTER, spaceAfter=3, fontName="Helvetica")

h1_style = make_style("H1", "Normal",
    fontSize=13, leading=18, textColor=WHITE,
    spaceBefore=14, spaceAfter=6,
    fontName="Helvetica-Bold", leftIndent=0)

h2_style = make_style("H2", "Normal",
    fontSize=11, leading=15, textColor=DARK_BLUE,
    spaceBefore=10, spaceAfter=4,
    fontName="Helvetica-Bold")

h3_style = make_style("H3", "Normal",
    fontSize=10, leading=14, textColor=MID_BLUE,
    spaceBefore=8, spaceAfter=3,
    fontName="Helvetica-BoldOblique")

body_style = make_style("Body", "Normal",
    fontSize=10, leading=15, textColor=colors.black,
    alignment=TA_JUSTIFY, spaceAfter=6, fontName="Helvetica")

bullet_style = make_style("Bullet", "Normal",
    fontSize=10, leading=14, textColor=colors.black,
    leftIndent=16, spaceAfter=3, fontName="Helvetica")

caption_style = make_style("Caption", "Normal",
    fontSize=8.5, leading=12, textColor=GREY,
    alignment=TA_CENTER, spaceAfter=4, fontName="Helvetica-Oblique")

ref_style = make_style("Ref", "Normal",
    fontSize=9, leading=13, textColor=colors.black,
    leftIndent=14, firstLineIndent=-14, spaceAfter=4, fontName="Helvetica")

story = []

# ═══════════════════════════════════════════════════════════════════════════════
# COVER PAGE
# ═══════════════════════════════════════════════════════════════════════════════
def cover_banner():
    data = [["RESEARCH PROPOSAL"]]
    t = Table(data, colWidths=[15.5*cm])
    t.setStyle(TableStyle([
        ("BACKGROUND",   (0,0), (-1,-1), DARK_BLUE),
        ("TEXTCOLOR",    (0,0), (-1,-1), WHITE),
        ("FONTNAME",     (0,0), (-1,-1), "Helvetica-Bold"),
        ("FONTSIZE",     (0,0), (-1,-1), 14),
        ("ALIGN",        (0,0), (-1,-1), "CENTER"),
        ("TOPPADDING",   (0,0), (-1,-1), 10),
        ("BOTTOMPADDING",(0,0), (-1,-1), 10),
    ]))
    return t

story.append(cover_banner())
story.append(Spacer(1, 0.5*cm))

story.append(Paragraph(
    "Factors Associated with the Rising Incidence of<br/>Caesarean Section Deliveries at<br/>"
    "Garissa Provincial General Hospital, Kenya",
    title_style))

story.append(Spacer(1, 0.4*cm))
story.append(HRFlowable(width="100%", thickness=2, color=GOLD, spaceAfter=10))

story.append(Paragraph("Submitted by", meta_style))
story.append(Paragraph("<b>ABDINASIR ALI</b>", subtitle_style))
story.append(Paragraph("Registration No.: D/CM/24017/862", meta_style))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph("Study Site:", meta_style))
story.append(Paragraph("Garissa Provincial General Hospital, Garissa County, Kenya", meta_style))
story.append(Spacer(1, 0.3*cm))
story.append(Paragraph("Date of Submission: May 2026", meta_style))
story.append(Spacer(1, 0.5*cm))
story.append(HRFlowable(width="100%", thickness=1, color=LIGHT_BLUE, spaceAfter=6))

# Declaration box
decl_data = [[
    Paragraph(
        "<b>Declaration:</b> This research proposal is submitted in partial fulfilment of the requirements for the "
        "award of the Diploma in Clinical Medicine. The work presented herein is original and has not been submitted "
        "to any other institution.",
        make_style("Decl","Normal",fontSize=9,leading=13,textColor=GREY,fontName="Helvetica-Oblique"))
]]
decl_table = Table(decl_data, colWidths=[15.5*cm])
decl_table.setStyle(TableStyle([
    ("BACKGROUND",   (0,0),(-1,-1), LIGHT_GREY),
    ("BOX",          (0,0),(-1,-1), 0.5, GREY),
    ("LEFTPADDING",  (0,0),(-1,-1), 10),
    ("RIGHTPADDING", (0,0),(-1,-1), 10),
    ("TOPPADDING",   (0,0),(-1,-1), 8),
    ("BOTTOMPADDING",(0,0),(-1,-1), 8),
]))
story.append(decl_table)
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# HELPER: section heading with coloured background bar
# ═══════════════════════════════════════════════════════════════════════════════
def section_heading(text, num=""):
    label = f"{num}. {text}" if num else text
    data = [[Paragraph(label, h1_style)]]
    t = Table(data, colWidths=[15.5*cm])
    t.setStyle(TableStyle([
        ("BACKGROUND",   (0,0),(-1,-1), DARK_BLUE),
        ("LEFTPADDING",  (0,0),(-1,-1), 10),
        ("RIGHTPADDING", (0,0),(-1,-1), 10),
        ("TOPPADDING",   (0,0),(-1,-1), 5),
        ("BOTTOMPADDING",(0,0),(-1,-1), 5),
    ]))
    return t

def sub_heading(text):
    return Paragraph(text, h2_style)

def sub_sub_heading(text):
    return Paragraph(text, h3_style)

def body(text):
    return Paragraph(text, body_style)

def bullet(items):
    entries = [ListItem(Paragraph(i, bullet_style), leftIndent=20, bulletColor=MID_BLUE) for i in items]
    return ListFlowable(entries, bulletType="bullet", leftIndent=10, spaceAfter=4)

def spacer(h=0.3):
    return Spacer(1, h*cm)

# ═══════════════════════════════════════════════════════════════════════════════
# TABLE OF CONTENTS (static)
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("TABLE OF CONTENTS"))
story.append(spacer(0.4))
toc_items = [
    ("1", "Introduction & Background"),
    ("2", "Problem Statement"),
    ("3", "Justification / Rationale"),
    ("4", "Research Questions"),
    ("5", "Objectives"),
    ("6", "Literature Review"),
    ("7", "Research Methodology"),
    ("8", "Ethical Considerations"),
    ("9", "Work Plan / Gantt Chart"),
    ("10", "Budget Estimate"),
    ("11", "References"),
]
toc_data = [[Paragraph(f"<b>{n}</b>", body_style), Paragraph(t, body_style), Paragraph("", body_style)] for n,t in toc_items]
toc_table = Table(toc_data, colWidths=[1.2*cm, 11.5*cm, 2.8*cm])
toc_table.setStyle(TableStyle([
    ("VALIGN",       (0,0),(-1,-1), "MIDDLE"),
    ("LINEBELOW",    (0,0),(-1,-1), 0.3, LIGHT_BLUE),
    ("TOPPADDING",   (0,0),(-1,-1), 4),
    ("BOTTOMPADDING",(0,0),(-1,-1), 4),
]))
story.append(toc_table)
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# SECTION 1 – INTRODUCTION & BACKGROUND
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("INTRODUCTION AND BACKGROUND", "1"))
story.append(spacer())
story.append(body(
    "Caesarean section (CS) is a life-saving surgical procedure used to deliver a baby through incisions "
    "in the abdominal wall and uterus when vaginal delivery poses unacceptable risks to the mother or "
    "foetus. Since the World Health Organization (WHO) set the recommended CS rate at 10–15% in 1985, "
    "the global incidence has continued to rise well beyond this threshold. By 2015, an estimated 29.7 million "
    "births worldwide — representing 21.1% of all deliveries — occurred by CS, nearly double the 16.0 million "
    "(12.1%) recorded in 2000 (Boerma et al., 2018)."
))
story.append(body(
    "In sub-Saharan Africa (SSA), CS rates have historically been among the lowest globally, predominantly "
    "reflecting under-use in resource-limited settings. However, a systematic review by Dumont et al. (2001) "
    "identified six principal maternal indications driving CS in West and East Africa: protracted labour, "
    "abruptio placentae, previous CS scar, eclampsia, placenta praevia, and malpresentation. As facility-based "
    "delivery rates in the region climb — from as low as 41% in 2003 to 88% nationally in Kenya by 2022 "
    "(KDHS 2022) — CS rates have risen correspondingly."
))
story.append(body(
    "Kenya's 2022 Demographic and Health Survey (KDHS) reports a national CS rate of 17% of all live births, "
    "with pronounced socioeconomic gradients: 34% among women with more than secondary education versus only "
    "3% among uneducated women. In north-eastern Kenya, home-birth rates remain the highest in the country "
    "(Mandera: 50%, Wajir: 46%), yet Garissa Provincial General Hospital (GPGH) — the sole Level 5 referral "
    "facility in the region — receives the most complex obstetric referrals from the three northern counties "
    "and neighboring areas."
))
story.append(body(
    "GPGH serves a predominantly Somali and Oromo Muslim pastoral community, where over 70% of residents live "
    "below the poverty line and where traditional birth attendants (TBAs) have historically dominated childbirth "
    "care. Recent infrastructure expansion (including DANIDA-funded construction and government specialist "
    "deployment) has significantly increased the hospital's surgical capacity and overall delivery volumes, "
    "creating the conditions for a measurable rise in CS rates that warrants formal investigation."
))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# SECTION 2 – PROBLEM STATEMENT
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("PROBLEM STATEMENT", "2"))
story.append(spacer())
story.append(body(
    "Caesarean section rates at Garissa Provincial General Hospital have been rising, yet no published "
    "peer-reviewed study has systematically identified and quantified the specific clinical, demographic, "
    "and health-system factors driving this increase at this institution. Without locally generated evidence, "
    "hospital administrators, clinical teams, and policymakers lack the data needed to distinguish medically "
    "necessary CS from potentially avoidable procedures, to allocate theatre resources efficiently, or to "
    "design targeted interventions."
))
story.append(body(
    "The consequences of unexamined rising CS rates are multi-dimensional: (i) increased short-term maternal "
    "morbidity (haemorrhage, surgical site infection, anaesthetic complications); (ii) accumulating 'previous-scar' "
    "burden that perpetuates repeat CS in future pregnancies; (iii) strain on limited theatre and blood-bank "
    "resources in an already resource-constrained facility; and (iv) ethical questions around informed consent "
    "and unnecessary surgery. A hospital-based study at GPGH is therefore urgently needed."
))

# ═══════════════════════════════════════════════════════════════════════════════
# SECTION 3 – JUSTIFICATION
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("JUSTIFICATION / RATIONALE", "3"))
story.append(spacer())
story.append(body(
    "This study is justified on the following grounds:"
))
story.append(bullet([
    "<b>Evidence gap:</b> No peer-reviewed study on CS rates and their determinants has been conducted "
    "specifically at GPGH or in Garissa County, leaving a critical gap in Kenya's obstetric evidence base.",
    "<b>Referral-hospital burden:</b> As the only Level 5 facility in northern Kenya, GPGH concentrates "
    "high-risk obstetric cases that would not appear in population-level surveys, making a facility-based "
    "study methodologically necessary.",
    "<b>Policy relevance:</b> Findings will directly inform GPGH's CS audit committee, clinical protocols, "
    "and north-eastern Kenya's county health management teams.",
    "<b>Resource stewardship:</b> Understanding avoidable versus indicated CS will guide rational use of "
    "theatre time, blood products, and skilled anaesthetic personnel.",
    "<b>Maternal safety:</b> Identifying primary CS over-use creates the evidence base for trial of labour "
    "after caesarean (TOLAC) programmes and birth companion models shown to reduce CS rates.",
]))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# SECTION 4 – RESEARCH QUESTIONS
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("RESEARCH QUESTIONS", "4"))
story.append(spacer())
story.append(bullet([
    "What is the current incidence of CS deliveries at Garissa Provincial General Hospital?",
    "What are the documented clinical indications for CS at GPGH, and what proportion of primary CS "
    "has no documented medical indication?",
    "What sociodemographic characteristics (age, parity, education, residence, ANC attendance) are "
    "independently associated with CS delivery at GPGH?",
    "What health-system factors (referral status, time of admission, surgical team availability) are "
    "associated with the CS decision at GPGH?",
    "What is the trend in CS rates at GPGH over the past five years (2020–2024)?",
]))

# ═══════════════════════════════════════════════════════════════════════════════
# SECTION 5 – OBJECTIVES
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("OBJECTIVES", "5"))
story.append(spacer())
story.append(sub_heading("5.1 Broad / General Objective"))
story.append(body(
    "To determine the factors associated with the rising incidence of caesarean section deliveries "
    "at Garissa Provincial General Hospital, Kenya."
))
story.append(sub_heading("5.2 Specific Objectives"))
story.append(bullet([
    "To determine the incidence and five-year trend of CS deliveries at GPGH (2020–2024).",
    "To identify the clinical indications documented for CS at GPGH and to determine the proportion "
    "of primary CS with no recorded medical indication.",
    "To assess the association between sociodemographic factors (maternal age, parity, education level, "
    "residence, ANC visits) and CS delivery at GPGH.",
    "To evaluate the role of health-system factors (referral status, hour of delivery, availability of "
    "specialist staff) in the decision to perform CS at GPGH.",
    "To compare CS rates stratified by parity, gestational age, and referral status.",
]))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# SECTION 6 – LITERATURE REVIEW
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("LITERATURE REVIEW", "6"))
story.append(spacer())
story.append(sub_heading("6.1 Global Trends in Caesarean Section"))
story.append(body(
    "The global CS rate has tripled from approximately 7% in 1990 to over 21% in 2015, representing "
    "29.7 million births annually (Boerma et al., 2018). The WHO (2021) projects this will reach "
    "28–30% by 2030 if current trends continue. The highest rates are in Latin America and the Caribbean "
    "(44.3%) and the lowest in West and Central Africa (4.1%). Globally, the rising proportion of "
    "facility-based deliveries accounts for 66.5% of the absolute increase in CS numbers, while "
    "increased CS use within facilities accounts for the remaining 33.5%."
))
story.append(sub_heading("6.2 CS Rates and Drivers in Sub-Saharan Africa"))
story.append(body(
    "Dumont et al.'s (2001) landmark systematic review across sub-Saharan Africa identified that "
    "three-quarters of all CS were performed for maternal indications. The six leading indications "
    "were: (1) protracted/obstructed labour, (2) abruptio placentae, (3) previous CS scar, "
    "(4) eclampsia, (5) placenta praevia, and (6) malpresentation. The authors estimated an optimal "
    "CS rate of 3.6–6.5% (median 5.4%) for West African populations — significantly above the "
    "observed 1.3%, indicating systemic under-use of life-saving CS in low-resource settings."
))
story.append(body(
    "A 20-year retrospective study in western Tanzania (Rapaport et al., 2024) of 8,461 CS procedures "
    "in an East African humanitarian setting found cephalopelvic disproportion (CPD), previous scar, "
    "and fetal distress as the top three indications — directly applicable to GPGH's case mix given "
    "comparable demographics, late-presentation patterns, and referral burdens."
))
story.append(sub_heading("6.3 Kenyan Evidence"))
story.append(body(
    "A Kenyan teaching-hospital analysis (van der Spek et al., 2020) of 12,209 deliveries found that "
    "43% of primary CS had no documented clinical indication in hospital records, and repeat CS was "
    "near-universal (99%). Socioeconomic differences in CS rates were largely explained by unnecessary "
    "primary CS and universal repeat CS after prior surgery. The authors recommended prevention of "
    "unnecessary primary CS and promotion of safe trial of labour."
))
story.append(body(
    "Arunda et al. (2020), analysing KDHS data for Kenya and Tanzania, found higher odds of CS among "
    "women from the richest households (aOR 1.4), those with health insurance (aOR 1.6), those with "
    "higher education (aOR 1.6), and managers/professionals (aOR 1.7), compared to their respective "
    "reference groups. However, CS was also associated with higher neonatal mortality overall — "
    "significance that disappeared after controlling for fetal risk factors and ANC visits, suggesting "
    "that medical complexity rather than the CS itself drove mortality."
))
story.append(body(
    "At Mama Lucy Kibaki Hospital, Nairobi (Juma et al., 2017), a case-control study found employment "
    "status and low birth weight as the two independent predictors of CS, reflecting urban patterns of "
    "demand-side CS use less likely to apply at GPGH."
))
story.append(sub_heading("6.4 Context of Garissa County"))
story.append(body(
    "GPGH is the sole Level 5 hospital in northern Kenya, serving Garissa, Wajir, and Mandera counties "
    "and acting as a teaching facility for clinical staff. Research on facility utilization at GPGH "
    "(Dabar, 2019) identified ANC attendance, hospital cleanliness, equipment availability, and "
    "proximity as determinants of delivery service utilization. The nomadic and semi-pastoralist "
    "lifestyle of the population (57% semi-pastoralism, 32% full nomadism), Islamic cultural norms, "
    "and poverty contribute to delayed presentations that increase emergency CS risk. No published study "
    "has directly examined CS incidence or its determinants at this institution."
))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# SECTION 7 – METHODOLOGY
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("RESEARCH METHODOLOGY", "7"))
story.append(spacer())

story.append(sub_heading("7.1 Study Design"))
story.append(body(
    "A hospital-based, retrospective cross-sectional study with an analytical component (case-control "
    "nested within the cross-section). Retrospective review of all delivery records from January 2020 "
    "to December 2024 will be undertaken, supplemented by prospective interviews of consenting mothers "
    "delivered at GPGH during the data-collection period."
))

story.append(sub_heading("7.2 Study Site"))
story.append(body(
    "Garissa Provincial General Hospital (Level 5), Garissa County, north-eastern Kenya. The hospital "
    "serves an estimated catchment population of over 1.5 million across Garissa, Wajir, and Mandera "
    "counties and several neighbouring counties."
))

story.append(sub_heading("7.3 Study Population"))
story.append(body(
    "<b>Target population:</b> All women who delivered at GPGH between January 2020 and December 2024. "
    "<b>Accessible population:</b> Women whose delivery records are available in the GPGH maternity register, "
    "theatre logbooks, and hospital information system."
))

story.append(sub_heading("7.4 Eligibility Criteria"))
story.append(sub_sub_heading("Inclusion Criteria"))
story.append(bullet([
    "All deliveries (vaginal and CS) recorded in GPGH maternity register, January 2020 – December 2024.",
    "Singleton and multiple pregnancies.",
    "Gestational age ≥ 28 weeks.",
    "Complete documentation of mode of delivery and at least one sociodemographic variable.",
]))
story.append(sub_sub_heading("Exclusion Criteria"))
story.append(bullet([
    "Records with incomplete or missing data on mode of delivery.",
    "Deliveries resulting in early pregnancy loss (< 28 weeks) not involving a CS.",
    "Women who delivered outside GPGH and were admitted post-partum.",
]))

story.append(sub_heading("7.5 Sample Size Determination"))
story.append(body(
    "Using the formula for estimating a proportion from a finite population (Cochran, 1977), with "
    "an assumed CS proportion of 25% (p = 0.25), margin of error of 5% (e = 0.05), and 95% confidence "
    "level (Z = 1.96):"
))
story.append(body(
    "<b>n₀ = Z² × p(1−p) / e² = (1.96)² × 0.25 × 0.75 / (0.05)² ≈ 288</b>"
))
story.append(body(
    "With a design effect of 1.5 for the retrospective component and 10% non-response allowance, "
    "the minimum sample is approximately <b>480 delivery records</b> for the cross-sectional analysis. "
    "For the retrospective trend analysis, all records from 2020–2024 will be included (estimated "
    "3,500–5,000 deliveries per year based on available facility data)."
))

story.append(sub_heading("7.6 Sampling Method"))
story.append(body(
    "For the cross-sectional/trend analysis: <b>census</b> of all eligible delivery records for "
    "2020–2024. For the prospective interview component: <b>systematic random sampling</b> — every "
    "3rd consenting mother admitted to the postnatal ward during the data-collection period."
))

story.append(sub_heading("7.7 Data Collection"))
story.append(sub_sub_heading("7.7.1 Secondary Data (Retrospective)"))
story.append(bullet([
    "Maternity register: mode of delivery, indication for CS, gestational age, parity, birth outcome.",
    "Theatre logbooks: time of CS, type (elective vs. emergency), primary vs. repeat CS.",
    "Hospital information system / patient files: maternal age, education, residence, ANC attendance.",
]))
story.append(sub_sub_heading("7.7.2 Primary Data (Prospective Interviews)"))
story.append(body(
    "A structured, interviewer-administered questionnaire will be developed in English and translated "
    "to Somali and Swahili. Variables collected will include: sociodemographic profile, obstetric history, "
    "ANC utilisation, referral status, maternal perceptions of CS, and birth preparedness."
))

story.append(sub_heading("7.8 Variables"))
data = [
    ["Variable Type", "Variables"],
    ["Dependent", "Mode of delivery (CS vs. vaginal)"],
    ["Independent – Obstetric", "Parity, gestational age, previous CS scar, presentation, fetal distress, APH, eclampsia, multiple gestation"],
    ["Independent – Sociodemographic", "Maternal age, education level, occupation, marital status, residence (urban/rural/nomadic), ANC visits"],
    ["Independent – Health-system", "Referral status (self vs. referred), day/hour of admission, surgeon availability, emergency vs. elective"],
]
var_table = Table(data, colWidths=[4.5*cm, 11*cm])
var_table.setStyle(TableStyle([
    ("BACKGROUND",   (0,0),(-1,0), DARK_BLUE),
    ("TEXTCOLOR",    (0,0),(-1,0), WHITE),
    ("FONTNAME",     (0,0),(-1,0), "Helvetica-Bold"),
    ("FONTNAME",     (0,1),(-1,-1), "Helvetica"),
    ("FONTSIZE",     (0,0),(-1,-1), 9),
    ("ROWBACKGROUNDS",(0,1),(-1,-1), [LIGHT_GREY, WHITE]),
    ("GRID",         (0,0),(-1,-1), 0.4, colors.grey),
    ("VALIGN",       (0,0),(-1,-1), "MIDDLE"),
    ("TOPPADDING",   (0,0),(-1,-1), 5),
    ("BOTTOMPADDING",(0,0),(-1,-1), 5),
    ("LEFTPADDING",  (0,0),(-1,-1), 6),
]))
story.append(spacer(0.2))
story.append(var_table)
story.append(spacer())

story.append(sub_heading("7.9 Data Management and Analysis"))
story.append(body(
    "Data will be entered into <b>SPSS version 25.0</b> (IBM Corp.) and verified by double-entry. "
    "Descriptive statistics (frequencies, proportions, means ± SD) will summarise the sample. "
    "The five-year CS trend will be tested using the <b>Cochran-Armitage test for trend</b>. "
    "Bivariate analysis (chi-square / Fisher's exact test for categorical variables; independent "
    "t-test or Mann-Whitney U for continuous variables) will identify candidate variables (p < 0.20) "
    "for multivariable logistic regression. A backward stepwise <b>binary logistic regression</b> model "
    "will determine independent predictors of CS (outcome: CS = 1, vaginal = 0), reporting adjusted "
    "odds ratios (aOR) with 95% confidence intervals. Statistical significance will be set at p < 0.05."
))
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# SECTION 8 – ETHICAL CONSIDERATIONS
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("ETHICAL CONSIDERATIONS", "8"))
story.append(spacer())
story.append(bullet([
    "<b>Ethical approval:</b> Approval will be sought from the relevant Institutional Review Board (IRB) "
    "and from the Garissa County Health Department before data collection commences.",
    "<b>Informed consent:</b> Written informed consent will be obtained from all participants in the "
    "prospective interview component. Consent forms will be available in English, Swahili, and Somali.",
    "<b>Confidentiality:</b> All records and questionnaires will be anonymised using unique numeric "
    "identifiers. Personal identifiers will be stored separately under lock and key, accessible only "
    "to the principal investigator.",
    "<b>Voluntary participation:</b> Participation in the interview component is entirely voluntary; "
    "refusal or withdrawal will not affect the quality of care received.",
    "<b>Retrospective records:</b> Review of existing hospital records constitutes secondary use of "
    "routine clinical data and will be conducted with hospital management permission in compliance "
    "with data protection standards.",
    "<b>Risk minimisation:</b> This is a non-interventional, observational study. No experimental "
    "procedures will be performed on participants.",
    "<b>Benefit:</b> Findings will directly benefit future patients at GPGH by informing evidence-based "
    "clinical guidelines and CS reduction strategies.",
]))

# ═══════════════════════════════════════════════════════════════════════════════
# SECTION 9 – WORK PLAN
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("WORK PLAN / GANTT CHART", "9"))
story.append(spacer())
story.append(body("Proposed timeline for study activities (12-month plan):"))
story.append(spacer(0.2))

months = ["M1", "M2", "M3", "M4", "M5", "M6", "M7", "M8", "M9", "M10", "M11", "M12"]
activities = [
    ("1", "Proposal writing & ethical approval", [1,1,1,0,0,0,0,0,0,0,0,0]),
    ("2", "Tool development & pretesting",         [0,0,1,1,0,0,0,0,0,0,0,0]),
    ("3", "Retrospective data extraction",          [0,0,0,1,1,1,0,0,0,0,0,0]),
    ("4", "Prospective data collection (interviews)",[0,0,0,0,1,1,1,0,0,0,0,0]),
    ("5", "Data entry & cleaning",                  [0,0,0,0,0,1,1,1,0,0,0,0]),
    ("6", "Data analysis",                          [0,0,0,0,0,0,0,1,1,0,0,0]),
    ("7", "Report writing",                         [0,0,0,0,0,0,0,0,1,1,0,0]),
    ("8", "Dissemination & submission",             [0,0,0,0,0,0,0,0,0,0,1,1]),
]

ACTIVE_COL = colors.HexColor("#005599")
INACTIVE_COL = colors.HexColor("#e8f0f8")

gantt_header = [["#", "Activity"] + months]
gantt_rows = []
for no, act, sched in activities:
    row_cells = []
    for active in sched:
        cell_para = Paragraph("■" if active else "", make_style(
            f"gantt_{no}_{active}", "Normal",
            fontSize=9, alignment=TA_CENTER,
            textColor=WHITE if active else INACTIVE_COL))
        row_cells.append(cell_para)
    gantt_rows.append([
        Paragraph(no, make_style("gcno","Normal",fontSize=8,alignment=TA_CENTER)),
        Paragraph(act, make_style("gcact","Normal",fontSize=8)),
    ] + row_cells)

all_gantt = gantt_header + [[
    Paragraph(str(r[0].text if hasattr(r[0],'text') else r[0]), make_style("gch","Normal",
        fontSize=8,textColor=WHITE,fontName="Helvetica-Bold",alignment=TA_CENTER))
    if i < 2 else
    Paragraph(r[2+j] if isinstance(r[2+j],str) else "", make_style("gchm","Normal",
        fontSize=8,textColor=WHITE,fontName="Helvetica-Bold",alignment=TA_CENTER))
    for i,(j,r) in enumerate([(0,row)] if False else [(0,0)])]
    for row in []]

# Build gantt table properly
gantt_header_row = [
    Paragraph("#", make_style("gh1","Normal",fontSize=8,textColor=WHITE,fontName="Helvetica-Bold",alignment=TA_CENTER)),
    Paragraph("Activity", make_style("gh2","Normal",fontSize=8,textColor=WHITE,fontName="Helvetica-Bold")),
] + [Paragraph(m, make_style(f"ghm{m}","Normal",fontSize=7,textColor=WHITE,fontName="Helvetica-Bold",alignment=TA_CENTER)) for m in months]

all_rows = [gantt_header_row]
for no, act, sched in activities:
    row = [
        Paragraph(no, make_style(f"gr{no}","Normal",fontSize=8,alignment=TA_CENTER)),
        Paragraph(act, make_style(f"ga{no}","Normal",fontSize=8)),
    ]
    for active in sched:
        row.append(Paragraph("", make_style(f"gc{no}{active}","Normal",fontSize=8)))
    all_rows.append(row)

col_widths = [0.6*cm, 5.2*cm] + [0.72*cm]*12
gantt_table = Table(all_rows, colWidths=col_widths)
gantt_style = [
    ("BACKGROUND",   (0,0),(-1,0), DARK_BLUE),
    ("TEXTCOLOR",    (0,0),(-1,0), WHITE),
    ("FONTSIZE",     (0,0),(-1,-1), 8),
    ("GRID",         (0,0),(-1,-1), 0.3, colors.lightgrey),
    ("ROWBACKGROUNDS",(0,1),(-1,-1), [LIGHT_GREY, WHITE]),
    ("TOPPADDING",   (0,0),(-1,-1), 3),
    ("BOTTOMPADDING",(0,0),(-1,-1), 3),
    ("LEFTPADDING",  (0,0),(-1,-1), 3),
    ("RIGHTPADDING", (0,0),(-1,-1), 3),
    ("VALIGN",       (0,0),(-1,-1), "MIDDLE"),
]
# Colour active cells
for row_i, (no, act, sched) in enumerate(activities, start=1):
    for col_i, active in enumerate(sched):
        if active:
            gantt_style.append(("BACKGROUND", (2+col_i, row_i), (2+col_i, row_i), ACTIVE_COL))

gantt_table.setStyle(TableStyle(gantt_style))
story.append(gantt_table)
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# SECTION 10 – BUDGET
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("BUDGET ESTIMATE", "10"))
story.append(spacer())
story.append(body("Proposed budget in Kenya Shillings (KES):"))
story.append(spacer(0.2))

budget_data = [
    ["Item", "Unit", "Qty", "Unit Cost (KES)", "Total (KES)"],
    ["Stationery (registers, pens, folders)", "Set", "5", "500", "2,500"],
    ["Printing of data collection tools", "Pages", "500", "5", "2,500"],
    ["Pilot study / pretesting", "Day", "2", "2,000", "4,000"],
    ["Research assistant allowance", "Month", "3", "10,000", "30,000"],
    ["Transport (data collection & follow-up)", "Trip", "20", "500", "10,000"],
    ["Data entry & analysis (SPSS licence)", "Month", "2", "5,000", "10,000"],
    ["Report printing & binding", "Copy", "10", "500", "5,000"],
    ["Dissemination (presentation materials)", "Lump sum", "1", "5,000", "5,000"],
    ["Contingency (10%)", "", "", "", "6,900"],
    ["TOTAL", "", "", "", "75,900"],
]
col_w = [6.0*cm, 2.5*cm, 1.2*cm, 3.0*cm, 2.8*cm]
budget_table = Table(budget_data, colWidths=col_w)
budget_table.setStyle(TableStyle([
    ("BACKGROUND",   (0,0),(-1,0), DARK_BLUE),
    ("TEXTCOLOR",    (0,0),(-1,0), WHITE),
    ("FONTNAME",     (0,0),(-1,0), "Helvetica-Bold"),
    ("FONTNAME",     (0,-1),(-1,-1), "Helvetica-Bold"),
    ("BACKGROUND",   (0,-1),(-1,-1), LIGHT_BLUE),
    ("GRID",         (0,0),(-1,-1), 0.4, colors.grey),
    ("ROWBACKGROUNDS",(0,1),(-1,-2), [LIGHT_GREY, WHITE]),
    ("FONTSIZE",     (0,0),(-1,-1), 9),
    ("ALIGN",        (2,0),(-1,-1), "RIGHT"),
    ("TOPPADDING",   (0,0),(-1,-1), 5),
    ("BOTTOMPADDING",(0,0),(-1,-1), 5),
    ("LEFTPADDING",  (0,0),(-1,-1), 6),
]))
story.append(budget_table)
story.append(PageBreak())

# ═══════════════════════════════════════════════════════════════════════════════
# SECTION 11 – REFERENCES
# ═══════════════════════════════════════════════════════════════════════════════
story.append(section_heading("REFERENCES", "11"))
story.append(spacer())

refs = [
    "Arunda, M. O., Agardh, A., & Asamoah, B. O. (2020). Cesarean delivery and associated socioeconomic "
    "factors and neonatal survival outcome in Kenya and Tanzania: analysis of national survey data. "
    "<i>Global Health Action, 13</i>(1), 1748403. https://doi.org/10.1080/16549716.2020.1748403 "
    "[PMID: 32345146]",

    "Boerma, T., Ronsmans, C., Melesse, D. Y., Barros, A. J. D., Barros, F. C., Juan, L., … Temmerman, M. "
    "(2018). Global epidemiology of use of and disparities in caesarean sections. "
    "<i>The Lancet, 392</i>(10155), 1341–1348. https://doi.org/10.1016/S0140-6736(18)31928-7 "
    "[PMID: 30322584]",

    "Dabar, M. (2019). <i>Factors affecting utilization of hospital delivery services at Garissa Provincial "
    "General Hospital</i> (MSc Public Health dissertation). Jomo Kenyatta University of Agriculture and "
    "Technology, Kenya. Retrieved from http://ir.jkuat.ac.ke/handle/123456789/5280",

    "Dumont, A., de Bernis, L., Bouvier-Colle, M. H., & Bréart, G. (2001). Caesarean section rate for "
    "maternal indication in sub-Saharan Africa: a systematic review. "
    "<i>The Lancet, 358</i>(9290), 1328–1333. https://doi.org/10.1016/S0140-6736(01)06414-5 "
    "[PMID: 11684214]",

    "Juma, S., Nyambati, V., Karama, M., Githuku, J., & Gura, Z. (2017). Factors associated with "
    "caesarean sections among mothers delivering at Mama Lucy Kibaki Hospital, Nairobi, Kenya between "
    "January and March 2015: a case-control study. "
    "<i>Pan African Medical Journal, 28</i>(Suppl 1), 7. "
    "https://doi.org/10.11604/pamj.supp.2017.28.1.9290",

    "Kenya National Bureau of Statistics. (2023). <i>2022 Kenya Demographic and Health Survey: Key "
    "Indicators Report</i>. Nairobi: KNBS / DHS Program. "
    "Retrieved from https://dhsprogram.com/pubs/pdf/SR277/SR277.pdf",

    "Kibe, P. M., Mbuthia, G. W., Shikuku, D. N., Akoth, C., Oguta, J. O., & Ng'ang'a, L. (2022). "
    "Prevalence and factors associated with caesarean section in Rwanda: a trend analysis of Rwanda "
    "demographic and health survey 2000 to 2019–20. "
    "<i>BMC Pregnancy and Childbirth, 22</i>(1), 424. "
    "https://doi.org/10.1186/s12884-022-04679-y [PMID: 35578320]",

    "Rapaport, S., Ngude, H., Chen, C. C. G., Abbas, M., Lekey, A., & Winch, P. J. (2024). Caesarean "
    "sections among East African refugees and their host population: a 20-year retrospective study in "
    "western Tanzania. <i>African Health Sciences, 24</i>(4). "
    "https://doi.org/10.4314/ahs.v24i4.27 [PMID: 40190504]",

    "Sandall, J., Tribe, R. M., Avery, L., et al. (2018). Short-term and long-term effects of caesarean "
    "section on the health of women and children. "
    "<i>The Lancet, 392</i>(10155), 1349–1357. https://doi.org/10.1016/S0140-6736(18)31930-5 "
    "[PMID: 30322585]",

    "van der Spek, L., Sanglier, S., Mabeya, H. M., van den Akker, T., Mertens, P. L. J. M., & "
    "Houweling, T. A. J. (2020). Socioeconomic differences in caesarean section — are they explained "
    "by medical need? An analysis of patient record data of a large Kenyan hospital. "
    "<i>International Journal for Equity in Health, 19</i>(1), 118. "
    "https://doi.org/10.1186/s12939-020-01215-2 [PMID: 32641057]",

    "World Health Organization. (2021, June 16). <i>Caesarean section rates continue to rise, amid "
    "growing inequalities in access</i>. WHO News. "
    "Retrieved from https://www.who.int/news/item/16-06-2021-caesarean-section-rates-continue-to-rise-"
    "amid-growing-inequalities-in-access",
]

for i, ref in enumerate(refs, 1):
    story.append(Paragraph(f"{i}.&nbsp;&nbsp;{ref}", ref_style))
    story.append(spacer(0.15))

# ═══════════════════════════════════════════════════════════════════════════════
# PAGE NUMBERS via onFirstPage / onLaterPages
# ═══════════════════════════════════════════════════════════════════════════════
def add_page_number(canvas, doc):
    canvas.saveState()
    # Footer bar
    canvas.setFillColor(DARK_BLUE)
    canvas.rect(2.5*cm, 1.5*cm, 16*cm, 0.5*cm, fill=1, stroke=0)
    canvas.setFont("Helvetica", 8)
    canvas.setFillColor(WHITE)
    canvas.drawString(3*cm, 1.68*cm, "ABDINASIR ALI | Reg: D/CM/24017/862")
    canvas.drawRightString(18.5*cm, 1.68*cm, f"Page {doc.page}")
    canvas.restoreState()

# ─── Build PDF ───────────────────────────────────────────────────────────────
doc.build(story, onFirstPage=add_page_number, onLaterPages=add_page_number)
print(f"PDF generated: {OUTPUT}")