Cesarean Section in the Gaza Strip: Factors and Implications
Samah Ahmad khalil AL-Attar
سماح أحمد خليل العطار
Statistics about the rates of cesarean section in Gaza are showing an alarming increase in the past 10 years, almost double than the internationally recommended figures. This study identifies factors behind the increased rate of cesarean section in Gaza. A mixed- method approach was used, in which data have been triangulated. In total, 160 (census study) relevant physicians had participated in the quantitative part with 90% response rate, and 390 beneficiaries’ records were reviewed. In addition, five in-depth interviews were conducted with purposively selected key informants. Quantitative data were collected through self-administered questionnaire and abstraction sheet were used in records review. The preliminary findings derived from the quantitative part had informed the qualitative data collection. The statistical Package for Social Sciences software was used for the quantitative data entry and analysis while the open coding thematic technique was used to analyze the qualitative data. Results showed that repeated CS, fetal distress, malpresentation, IVF and obstructed labor were the most common indications for CS as reported by physicians (83.3%, 77.6%, 73.6%, 61.1% and 45.8% respectively). Records review confirmed these factors. Nearly quarter of respondents (24.3%) admitted that there is no written protocol for management of CS at their work. Work overload, too much duties and lack of supervision (25.8%, 13.4%, 13.4% respectively), were the most commonly reported reasons behind not applying the protocol. Furthermore, fear of litigation was the most common organizational related factor that affects CS, followed by continuous electronic fetal monitoring, lack of protocols and inadequate supervision (53.5%, 45.1%, 39.6% and 39.6% respectively). Inferential analysis from records review showed that non-governmental hospital has statistically significant higher rate of primary CS than governmental hospitals (p=0.001). Results from the qualitative study were supportive to the quantitative findings as key informants reported that the rate of CS is increasing. Fear of litigation and social pressure in addition to private sector were among the reasons behind increase the rate. Findings emphasized the importance of standardization of management of intrapartum CTGabnormalities according to national Obstetric Guidelines and Labor Ward Protocols, enhance Vaginal Birth After Cesarean and pay more attention to decrease primary CS. Moreover, implementation of monitoring, evaluation, accountability and learning system in all health facilities and practices will help to rationalize the use of CS.