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Factors associated with the rising incidence of Caesarean section deliveries at Garissa Provincial General Hospital, Kenya. I want a research on this and also previous one according to the topic

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Factors Associated with the Rising Incidence of Caesarean Section Deliveries at Garissa Provincial General Hospital (GPGH), Kenya

Overview & Context

Garissa Provincial General Hospital (GPGH) is the sole Level 5 referral hospital serving the three counties of north-eastern Kenya (Garissa, Wajir, Mandera) and neighboring counties. It operates in a predominantly arid, pastoralist Muslim region where more than 70% of residents live below the poverty line and where home deliveries historically dominated. As facility-based delivery rates have climbed — driven in part by partner support (notably DANIDA), staff expansion, and increased specialist presence — the absolute number and proportion of caesarean section (CS) deliveries have risen correspondingly.
According to the 2022 Kenya Demographic and Health Survey (KDHS), 17% of all live births in Kenya are now delivered by CS — up sharply from about 5% two decades earlier. Facility delivery nationally reached 88% in 2022 (up from 41% in 2003). In north-eastern Kenya, counties like Mandera (50% home births), Wajir (46%), and Garissa still lag in facility utilization, yet GPGH itself, as the apex referral facility for a vast catchment, handles the most complex obstetric cases.

1. Obstetric / Clinical Indications (Most Proximate Drivers)

These are the direct medical reasons driving the CS decision at GPGH and comparable East African hospitals:

a) Previous Caesarean Scar

The single most powerful predictor of CS across every African hospital studied. In a large Kenyan teaching hospital analysis (van der Spek et al., 2020, PMID 32641057), repeat CS was near-universal at 99% — meaning almost every woman with a prior scar delivered surgically again, driving the accumulating stock of CS deliveries. Primary CS thus has a cascade effect on all subsequent pregnancies.

b) Cephalopelvic Disproportion (CPD) / Obstructed Labour

CPD and prolonged/obstructed labour are the leading primary indications across sub-Saharan Africa. The systematic review by Dumont et al. (2001, Lancet, PMID 11684214) — the only published systematic review of CS rates for maternal indication in sub-Saharan Africa — identified protracted labour and CPD as the most common reasons for CS in West and East African hospital populations. This is directly applicable to GPGH, where young, nulliparous, undernourished women from pastoral communities often present late in obstructed labour after attempting home delivery.

c) Fetal Distress

Intrapartum fetal heart rate abnormalities prompting emergency CS. In the 20-year East African retrospective from Tanzania (PMID 40190504), the three top CS indications were CPD, previous scar, and fetal distress — consistent with GPGH's likely case mix given its role as the terminal referral for complicated labour.

d) Malpresentation (Breech, Transverse Lie)

Malpresentation is a major indication, particularly relevant in high-parity, grand-multiparous Somali/Oromo women in the GPGH catchment, where late ANC registration may mean malpresentation is detected only at onset of labour.

e) Antepartum Haemorrhage (Placenta Praevia, Abruptio Placentae)

Dumont et al.'s systematic review placed abruptio placentae and placenta praevia among the six principal maternal indications for CS in sub-Saharan Africa. These obstetric emergencies mandate immediate CS.

f) Pre-eclampsia / Eclampsia

Eclampsia is a consistent indication. In the MOMA survey population across West Africa, eclampsia featured among the six top indications. GPGH, with its referral burden, receives eclamptic women from a wide area.

g) Multiple Pregnancy

Kibe et al. (2022, PMID 35578320) — analyzing two decades of Rwanda DHS data — found multiple gestation independently associated with CS after adjustment for other factors.

2. Sociodemographic Factors

a) Referral Status & Catchment Burden

GPGH is the only Level 5 hospital in northern Kenya, receiving referrals from Level 2–4 facilities across a vast, sparsely populated region. Cases reaching GPGH are inherently higher-risk (prolonged labour, failed trial of labour, antepartum haemorrhage) — automatically elevating CS rates above what community-level rates would suggest.

b) Delayed Presentation

Pastoral nomadism (57.1% semi-pastoralism in Garissa District) and distances to the facility mean many women present in advanced or obstructed labour. Late arrival limits the window for successful vaginal delivery and increases emergency CS rates.

c) Maternal Age & Parity

Both extremes carry risk: adolescent patients with CPD, and grand-multiparous women (common in this high-fertility community) with malpresentation or uterine hypotonia. Arunda et al. (2020, PMID 32345146) found that among facility-delivered births in Kenya, grand multiparity was not protective against CS when obstetric risk factors were present.

d) Education & Wealth

The KDHS 2022 documents a stark gradient: CS rate of 34% among women with more than secondary education vs. 3% among uneducated women nationally. In Garissa County — one of Kenya's most educationally deprived — population-level CS rates remain lower than the national average, but within GPGH (as a referral hospital), the medical case-mix dominates rather than socioeconomic elective demand.

e) ANC Utilization

Paradoxically, higher ANC attendance is associated with increased CS in some East African studies (including Kibe et al. 2022 for Rwanda), likely because high-risk pregnancies are identified and followed up. Conversely, women presenting to GPGH without ANC (common in nomadic populations) tend to arrive with undiagnosed complications — also driving emergency CS.

3. Health System & Institutional Factors

a) Expanding Facility Capacity

DANIDA-funded infrastructure expansion and government specialist deployment at GPGH increased surgical capacity. As noted in JKUAT research on GPGH (Dabar, 2019), hospital expansion and improved equipment directly drove increased facility utilization — more deliveries overall, and more CS among complicated cases.

b) Rising Facility Delivery Rate

WHO data show that globally, 66.5% of the increase in CS deliveries is attributable to more births occurring in health facilities, not to higher CS rates within facilities (Boerma et al., 2018, Lancet, PMID 30322584). As women previously delivering at home migrate to GPGH, the hospital's CS denominator increases.

c) Availability of Surgical Teams

Greater availability of obstetricians and anaesthetic officers at GPGH — compared to peripheral facilities — means that surgical capability exists where it previously did not. The threshold for CS may lower when skilled staff are present and theatre is available.

d) Lack of Clear Guidelines / Audit Culture

Van der Spek et al. (2020, Kenya) found that 43% of primary CS had no documented clinical indication in hospital records, and over-use was measurable even at the primary CS level. Without robust CS audit and second-opinion protocols, institutional CS rates drift upward over time.

e) Financial Incentives

In Kenyan private and semi-private settings, CS generates higher facility revenue than vaginal delivery. While GPGH is a public hospital, this dynamic has documented effects on overall national CS rates (Boerma et al., 2018; Arunda et al., 2020).

4. Patient-Level Demand & Cultural Factors

a) Growing Acceptance of Hospital Delivery

Historically, Somali cultural and religious norms favoured traditional birth attendants (TBAs). As community attitudes shift — through health education and improved facility quality — more women choose or are referred to GPGH, including cases that would previously have delivered without documentation.

b) Perceived Safety of CS

In urban Kenyan settings, employment was associated with CS delivery at Mama Lucy Kibaki Hospital, Nairobi (Juma et al., 2017, Pan African Medical Journal), possibly reflecting perception that CS is a safer or more "modern" option. Though less relevant in rural Garissa, this trend may emerge as education and wealth levels rise.

5. Global & Regional Trends as Background

YearGlobal CS RateEast/Central Africa
1990~7%~3–5%
2000~12%~4–6%
2015~21%~10–12%
2022~23–25%increasing
(Sources: WHO 2021; Boerma et al., Lancet 2018)
WHO's 2021 statement notes that global CS rates have tripled since 1990 and are projected to reach 28% by 2030. Sub-Saharan African rates are the lowest globally but rising fastest in percentage terms, driven by urbanization, facility expansion, and shifting patterns of obstetric risk.

6. Summary Table of Key Factors at GPGH

CategoryFactorDirection of Effect
ObstetricPrevious CS scar↑↑ (strongest driver)
ObstetricCPD / obstructed labour↑↑
ObstetricFetal distress↑
ObstetricMalpresentation↑
ObstetricAPH / placenta praevia↑
ObstetricEclampsia↑
SystemSole regional referral hospital↑ (high-risk case concentration)
SystemFacility infrastructure expansion↑
SystemRising facility delivery rates↑
SystemAbsent CS audit↑
DemographicDelayed presentation, long distances↑
DemographicYoung primigravidae / adolescents↑
SocioeconomicLow ANC uptake in nomadic women↑ (undetected complications)

Key References (Peer-Reviewed)

  1. Dumont A et al. (2001). Caesarean section rate for maternal indication in sub-Saharan Africa: a systematic review. Lancet. PMID 11684214 — Six main indications: protracted labour, abruptio placentae, previous CS, eclampsia, placenta praevia, malpresentation.
  2. Boerma T et al. (2018). Global epidemiology of use of and disparities in caesarean sections. Lancet. PMID 30322584 — Global CS doubled 2000–2015; 66.5% of increase driven by facility delivery rise.
  3. van der Spek L et al. (2020). Socioeconomic differences in caesarean section — are they explained by medical need? Int J Equity Health. PMID 32641057 — Kenyan hospital: repeat CS 99%, 43% primary CS undocumented; previous scar & unnecessary primary CS drive rates.
  4. Arunda MO et al. (2020). Cesarean delivery and associated socioeconomic factors and neonatal survival in Kenya and Tanzania. Glob Health Action. PMID 32345146 — Wealth, insurance, education, and urban residence independently associated with CS in Kenya.
  5. Kibe PM et al. (2022). Prevalence and factors associated with caesarean section in Rwanda (DHS 2000–2019-20). BMC Pregnancy Childbirth. PMID 35578320 — CS rose from 2.2% to 15.6% over 20 years; multiple pregnancy, high socioeconomic status, ≥4 ANC visits as independent predictors.
  6. Rapaport S et al. (2024). Caesarean sections among East African refugees and host population: 20-year retrospective, Tanzania. Afr Health Sci. PMID 40190504 — CPD, previous scar, fetal distress: top three indications across 8,461 CS in an East African humanitarian setting demographically similar to GPGH.
  7. Juma S et al. (2017). Factors associated with caesarean sections at Mama Lucy Kibaki Hospital, Nairobi, Kenya. Pan African Medical Journal. — Employment and low birth weight associated with CS in urban Kenya.
  8. Kenya NDHS 2022 (DHS Program) — 17% national CS rate; gradient by education (3% no education → 34% post-secondary); facility births 88%.

Recommendations for GPGH (Evidence-Based)

  • CS audit committee: Regular case review to identify and reduce non-indicated primary CS, consistent with van der Spek et al. findings.
  • Trial of labour after caesarean (TOLAC) protocols: Safely reduce repeat CS burden where appropriate.
  • Strengthen ANC outreach in nomadic communities: Earlier detection of malpresentation, multiple gestation, and CPD risk allows planned intervention and reduces emergency CS.
  • Safe obstetric drill training: Improving management of prolonged labour and fetal distress at peripheral facilities reduces the late-referral CS rate.
  • Data collection: GPGH should maintain prospective CS indications registers to generate locally specific evidence, as no published studies specific to Garissa County CS factors currently exist in peer-reviewed literature.

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