Prevalence, Indications and Morbidity of Caesarean Sections in a Referral Hospital of the Health Voucher Program: The Case of Garoua Regional Hospital in the Northern Region of Cameroon ()
1. Introduction
Caesarean section (CS) is a surgical procedure performed to remove a fetus from the mother’s uterus through an incision on the abdominal wall, then on the uterine wall. It is an old obstetrical procedure whose origins are controversial, and which has undergone several innovations over the years [1] . Worldwide, caesarean section rates have risen in recent decades. According to recent estimates of over 150 countries, 21% of all births occur through caesarean section, with averages ranging from 1% to 58% depending on the country. The World Health Organization (WHO) estimates that the global caesarean section rate has almost tripled in a quarter of a century [2] . The indications of CS vary not only between countries, but also from one hospital to another and from one team to another within the same hospital [3] . The procedure is the result of an intellectual approach specific to each practitioner, given the limited internationally adopted consensus. The indications for caesarean section have evolved considerably, and this evolution is not yet complete.
Despite advances in asepsis and anesthesia/resuscitation technics, there are still complications of varying severity inherent to the gravid-puerperal state on one hand [4] and the surgical technics used on the other, irrespective of the operative indication [5] . That was our motivation for conducting this survey.
As far as we know, there are very few up-to-date studies on the prevalence and indications of caesarean section in Cameroon, especially in the northern region. Thus, the present study was carried out with the objectives of determining the prevalence, and identifying the indications and morbidity linked to caesarean sections in our environment.
Cameroon has also set up a health voucher program in its northern region, aimed at reducing maternal morbidity and mortality. The program aims to improve financial access to CS in this low-income region of the country by subsidizing pregnancy care and deliveries, including caesarean sections.
2. Materials and Method
2.1. Study Design
We conducted a descriptive cross-sectional study with retrospective data collection.
2.2. Site Justification
The town of Garoua was chosen because of the cultural and social values in northern Cameroon which are in favor of fertility, the presence of subsidy programs for the fight against maternal and perinatal mortality. It also has a CEmONC regional hospital, which is the referral center for the North. Our study was carried out in the department of Obstetrics and Gynecology of the Garoua Regional Hospital (GRH).
2.3. Study Period
The study ran from February 1, 2022, to May 31, 2022.
2.4. Study Population
Target population
All women admitted in the labor ward and who have given birth.
Source population
The population of our study will consist of all women who gave birth by caesarean section in the department of Obstetrics and Gynecology of the Garoua regional hospital.
Inclusion criteria
All women who gave birth by caesarean section were included in the study.
Exclusion criteria
All files with incomplete information were excluded, as well as all women who had undergone caesarean section in other health facilities but were managed at the Garoua Regional Hospital.
2.5. Sampling Method
We used a non-probabilistic sampling, and our sample size was exhaustive, meeting the selection criteria during the study period, that is, 226 cases included in our study. We collected data on pre-established questionnaire, by using patient files, delivery room registers and operative room registers.
2.6. Variables
We evaluated following variables: caesarian delivery, age, religion, education, marital status, parity, occupation, caesarian indications, maternal complications, fetal complications, history of caesarean section, term of pregnancy.
2.7. Materials
Data collection sheets, medical records, computer equipment including a laptop with CSpro and SPSS software, Microsoft Word and Excel, cell phone, internet connection tools (modem). Office equipment: A4 paper, ballpoint pens, pencils, erasers.
2.8. Data Analysis
The data collected and recorded on the survey form were then entered and analyzed using CSpro-7.3, SSPS 26.0, Microsoft EXCEL and Word version 2016. The results of the study are presented in tables and figures; expressed as proportions and numbers for categorical variables. Quantitative variables are expressed as means with standard deviation.
The findings of the study are classified by quantitative and qualitative variables, which are represented in the form of figures and tables.
3. Results
3.1. Participant Recruitment
In our study series, out of 905 parturient admissions into the department of Obstetrics and Gynecology and during the period from February 1, 2022, to May 31, 2022, we recorded 226 cesarean sections which were included in our study (Figure 1).
3.2. Prevalence of Caesarean Sections during the Study Period
The overall frequency during our study period was 25%. A monthly study of caesarean section frequency reveals that the highest rate was observed in March, with 26.5% of cases, and the lowest rate in February and May, with 24.3% of cases respectively (Figure 2).
3.3. Sociodemographic Characteristics of Pregnant Women
The mean age of patients operated on was 25.93 ± 6.36 years, with extremes of
14 and 43 years. Most of the women were aged between 20 and 29 years (49.6%), married (83.2%), muslims (60.2%), living in urban areas (76.5%). The majority had primary education (41.2%) and were housewives (71.7%) (Table 1).
3.4. Clinical Aspects Mode and Reason for Admission
Most patients were referred from a health facility (82.7%). Lumbopelvic labor—like pains was the most common chief complaint (34.1%) (Table 2).
3.5. Obstetrical History
Primigravida and nulliparity were most common in 37.6% and 42.5% of cases respectively (Table 3).
![]()
Figure 2. Prevalence of caesarean section by month.
![]()
Table 1. Distribution of study population by socio-demographic characteristics.
![]()
Table 2. Distribution by mode of admission and reason for consultation
![]()
Table 3. Distribution by gravidity and parity.
3.6. Medical and Surgical History
High blood pressure was found in 5.3% of patients undergoing surgery. 21.2% of patients hadundergone a previous caesarean section and 2.2% a laparotomy indicated for ectopic pregnancy (Table 4).
3.7. Pregnancy Follow-Up
The average number of prenatal consultations was 3.99 ± 1.74, with a minimum of 0 and a maximum of 8. Most of the women who underwent surgery had average ANC (64.6%), and 76.1% of them were managed by the health voucher program. Pregnancy follow-up was carried out in health centers (74.8%), largely by midwives (35.8%) (Table 5).
3.8. Clinical Signs
Most patients were at term (78.3%), and 19% had elevated blood pressure. Fetal heart rate anomalies were observed in 12.8% of admissions. Membranes were ruptured in 31%, and pelvic quality was abnormal in 4.9% of cases. The presentation was cephalic in most cases (81.0%) (Table 6).
3.9. Caesarean Section Indications
Caesarean section procedure
Caesarean sections were performed as an emergency procedure in the majority of cases (91.2%). The majority of procedures were performed under general anesthesia (85.8%). Close to half of caesarean sections were performed by gynecologists (47.3%). Pfannenstiel incision was performed in over 50% of patients, meanwhile transverse hysterotomy was done in all cases operated (100%) (Table 7).
The average procedure duration was 44.98 ± 14 min, with a minimum of 25 minutes and a maximum of 90 minutes. The procedures most associated with
![]()
Table 4. Distribution according to medical and surgical history.
![]()
Table 5. Pregnancy follow-up distribution.
![]()
Table 6. Distribution according to clinical.
![]()
Table 7. Distribution by type of caesarean section, anesthesia, provider, and incision type.
caesarean section were bilateral tubal ligation (2.7%), appendectomy (2.7%), emergency obstetric hysterectomy (2.2%) and ovarian cystectomy (1.8%) (Table 8).
3.10. Main Indications
The main maternal indications for caesarean section were scarred uterus (12.4%), followed by severe pre-eclampsia (11.1%) and pre-uterine rupture syndrome (5.3%). Fetal indications were dominated by cephalopelvic disproportion and non-reassuring fetal heart in 17.3% and 13.7% of cases respectively (Table 9).
![]()
Table 8. Distribution by duration of operation and associated procedures.
![]()
Table 9. Distribution by caesarean section indications.
Others*: Cord prolapse, Post term/Post datism, Induction failure, Convenience...
3.11. Operative Complications
Maternal prognosis
Intraoperative complications were dominated by hemorrhage (15.5%) and bladder lesions (4.9%), while postoperative complications were mainly abdominal wall suppuration (4.4%), endometritis (3.5%), burst abdomen/suppuration (0.9%), thromboembolic disease,and maternal death (0.4% respectively) (Table 10).
3.12. Fetal Prognosis
In our study, we noted 11.1% perinatal mortality, with 8.8% stillbirths and 2.3% early neonatal death (Figure 3).
![]()
Figure 3. Distribution by fetal prognosis at birth.
4. Discussion
4.1. Prevalence of Caesarean Sections
The prevalence (25%) of caesarean sections at the Garoua Regional Hospital was higher than that recommended by WHO. It was same situation for Bokossa et al. [6] in Ivory Coast, which was 31.3%. Essiben et al. in 2017 in Yaounde-Cameroon found a prevalence of 29.6% [7] . This prevalence remains relatively high due to the fact that Garoua Regional Hospital receives parturients from other health facilities in the northern region. The health voucher scheme also promotes access to caesarean sections.
4.2. Socio-Demographic Characteristics of the Study Population
The mean age of operated patients was 25.93 ± 6.36 years, with extremes ranging from 14 to 43 years. Most were aged between 20 and 29 years (49.6%). Mpogoro et al., [8] in Tanzania in 2014 found a mean age of 26.8 ± 5.8 years with extremes ranging from 14 to 44 years, the most represented age range in their study was 20 to 34 years. These results can be explained by the fact that, at this age, women are at the peak of their reproductive role.
The youngest patients were 14 years and the oldest 43years. These two extremes come as no surprise, as Fouedjio et al. [9] in Cameroon in 2021, reported extremes ranging from 14 to 46 years, while Barbut et al. [10] in France in 2004 reported extremes from 19 to 45 years. This difference can be explained by the fact that we face maternal health challenges such as early pregnancy and poor access to contraceptive methods, but also by the low level of education in our context.
Most of them were housewives (71.7%). This is probably because the majority of patients had a primary level of education (41.2%) and were illiterate (36.7%), but also because of early marriage in the region. The same observation was made by Teguete et al. [11] and several other studies in Mali, who reported that the majority of women operated on by caesarean section were over 90% illiterate. In the other hand, we observed that majority of women was muslims (60.2%), like Mali’s authors, because Muslims are mostly represented in this region of the country.
4.3. Admission Mode
Most deliveries were referred from a health facility (82.7%). Ouédraogo et al. [12] in Burkina Faso found a 91.9% referral rate. The hypothesis that would justify this high referral rate is the level of attainment of the health voucher program to parturients in this region. In addition, Garoua Regional Hospital is a referral hospital with qualified staff and technical equipment for performing caesarean sections.
4.4. Obstetrical History
Primigravida and nulliparity were most represented in 37.6% and 42.5% of cases. This confirms the data in the literature review which shows that primigravidas have an increased risk of caesarean delivery, as they have an untested pelvis.
Since our study population was dominated by nulliparous, we have encountered few patients with a scarred uterus, 21.2%, contrarily to Guindo and Keita who find out rate of 65.21% and 67.3% in Mali [13] .
4.5. Clinical Aspects
The average number of prenatal consultations was 3.99 ± 1.74, with a minimum of 0 and a maximum of 8. Most of the women who underwent surgery had normal prenatal consultations (64.6%) due to health voucher program, and 76.1% of them were managed by this program.
Pregnancies were followed up in health centers (74.8%) by qualified personnel like midwives (35.8%). In Yaoundé, on the same vein, Essiben et al. [7] found a follow-up rate of 93.7%, amongst which 62.6% of which were done by obstetrician-gynecologists. However, there is a shortage of obstetrician-gynecologists in Cameroon northern region.
Few patients present ruptured membranes in 31%, less than what Coulibaly et al. [14] reported 47% of cases of ruptured membranes.
4.6. Management
Indications for caesarean section were dominated by cephalopelvic disproportion and fetal distress in 17.3% and 13.7% of cases respectively. Nkwabong et al. [15] in Cameroon found that cephalopelvic disproportion was the most frequent indication in 24.0% of cases. These results can be explained by the fact that most of the patients were primigravida and nulliparous, and therefore had pelvis that had never benefited from a trial of labor.
The health voucher program subsidizes caesarean sections, and imposes referral system. So, Caesarean sections were emergencies in the majority of cases (91.2%), similar to the 96.4% observed in Burkina Faso by Ouédraogo et al. [12] . However, our prevalence remains higher than those observed in France by Toulon and Palot [16] , who reported emergency caesarean section rates of 61.0% and 64.0% respectively.
Most operations were performed under general anesthesia (85.8%). This is due to the observation that the surgical kits in the health voucher program are made up of general anesthesia drugs and materials.
4.7. Complications
Intraoperative complications were dominated by hemorrhage (15.5%) and bladder lesions (4.9%), mainly due to the urgent nature of Caesarean sections.
Post-operative complications were infectious in 8.8%, represented by wall sepsis (4.4%), endometritis (3.5%) and evisceration/suppuration (0.9%). Kemfang et al. [17] in Yaounde-Cameroon reported a frequency of infectious complications in 7.6% of cases. This could be explained by the non-observance of antibiotic prophylaxis by some surgical patients due to financial limitations, especially as the majority were housewives (71.7%) with no source of income since, the health voucher program does not provide postoperative antibiotics for caesarean patients.
Maternal death was observed in 0.4% of cases. This is lower than the rate observed by Cissé et al. [18] in Dakar, which was 0.8%. This relatively low rate is justified by the fact that most caesarean sections are covered by the health subsidy program (76.1%), but also by the permanent mobilization and quality of the high-performance staff at the Garoua Regional Hospital.
In our study, perinatal mortality was 11.1%, with 8.8% stillbirths and 3.1% early neonatal death. This could be linked to fetal distress being a significant indication for emergency obstetric care in our series (13.7%), increasing the risk of perinatal asphyxia and consequently death. This high mortality rate can also be explained by the difficulties associated with inadequate neonatal care, notably the lack of medical equipment and consumables.
5. Limitations of Our Study
Some files could not be found, and others were unusable, this could influence the representability of the population.
6. Conclusion
Cameroon is a low-income country with limited resources, especially in the Northern region. The health voucher program has improved financial access to caesarean sections for parturients in northern Cameroon, and consequently to emergency obstetric and neonatal care. The prevalence of caesarean section is relatively high at Garoua regional hospital, with a frequency of 25%. Most of those operated on were aged between 20 and 29, with a primary level of education (41.2%), primigravida and nulliparity in 37.6% and 42.5% of cases respectively. Caesarean sections were performed urgently in the majority of cases (91.2%). The main indications were cephalopelvic disproportion (17.3%) and acute fetal distress (13.7%). Infectious complications accounted for 8.8%, and maternal death was rare (0.4%).
Acknowledgements
The authors are grateful to the administrative staff of the Garoua Regional Hospital for authorizing and facilitating the conduct of this study. Our thanks also go to the staff of the maternity department for their contribution during data collection. It is the personal contribution of each author that made this study possible; no funding was granted.