The Prevalence of C-Section Delivery and Its Associated Factors Among Saudi Women Attending Different Clinics of King Khalid University Hospital

Objective Cesarean section (C-section) is one of the most common surgical procedures worldwide that may be performed to deliver one or more newborns. The objective of our study was to determine the prevalence of C-section delivery among Saudi women attending different clinics of King Khalid University Hospital (KKUH) who were pregnant, previously pregnant, and had delivered. Methods A quantitative observational cross-sectional study using a self-administered questionnaire that has been handed to the participants after explaining the purpose of the study. A total of 524 pregnant and non-pregnant women were enrolled in the study randomly collected from all female clinics of KKUH. The study sample were given a self-administered questionnaire. Data were analyzed using the Statistical Package for Social Sciences (SPSS), version 21 (IBM SPSS Statistics, Armonk, NY) to analyze the data. Results Of the 524 study participants, 32.6% underwent C-section. There was a statistical significance in women aged 23 years old, as well as teachers, in relation to undergoing C-section (p-values = 0.0001 and 0.044, respectively). We concluded that malpresentation is the most common medical indication, with an overall percentage of 25%. There was no evident statistical association between body mass index (BMI), the highest level of education, marital status, Income status, mode of delivery, and the number of normal births or stillbirths. Conclusion It was found that the prevalence of Saudi women attending KKUH who underwent C-section was 32.6%. Medical indications to undergo C-sections, in comparison to the non-medical ones, were higher. Malpresentation was the most common medical indication, with an overall percentage of 25%.


Introduction
Pregnancy is when a woman carries a developing embryo in her womb [1]. There are two modes of delivery, one of them is vaginal delivery and the less common mode is the cesarean section (C-section). C-section is one of the most common surgical procedures worldwide that may be performed to deliver one or more newborns [2][3]. C-sections performed appropriately and following appropriate medical indications are potentially life-saving procedures. There is a substantial increase in women who are undergoing C-section without any medical indication, and this may be the reason behind the global trend towards higher rates of C-section [4]. During the past several decades, cesarean deliveries in both developed and developing countries have reached an alarmingly high rate. Based on a study conducted by the World Health Organization (WHO) in 2008, it was estimated that approximately 18.5 million C-section procedures were performed yearly with 69 countries having C-section rates above 15% [3]. In Saudi Arabia, the C-section rate accounts for around 10% of all births, reaching 20% in tertiary centers. The observed increase in cesarean birth has been attributed to many factors, including the first birth, in particular, and advanced maternal age. Other factors include the obstetrician's characteristics and care practices [5]. Assessment of the current situation regarding the increasing numbers of C-section in the Kingdom of Saudi Arabia (KSA) consequently increases the number of complications for the mother and child if it is not due to a life-threatening medical indication, not to speak of its economic impact on the families. Although the surgery might be preferred in cases of a medical indication, it still has its surgical risks that may jeopardize both the mother and child's health [2]. Recently, C-sections have been performed to satisfy women's desire; therefore, cesarean delivery on maternal request (CDMR) was added to the known common C-section indications [6]. Our study aims to contribute to the process of raising awareness regarding the perceived idea that C-section is safer than normal delivery by pinpointing the factors that influence women's choice of delivery.
There are a limited number of studies conducted in Saudi Arabia and, more specifically, in Riyadh that studied or quantified the associated factors that influence women's choice of undergoing C-section delivery. In our research, our objective is to determine the prevalence of C-section delivery among Saudi women attending different clinics of King Khalid University Hospital (KKUH) who were pregnant, previously pregnant, and those women who had delivered.

Materials And Methods
This study was approved by the Institutional Review Board at King Saud University (KSU) College of Medicine. Oral or written consent was obtained from study subjects prior to administering a questionnaire. Names and other identifying information from the study subjects were not requested during data collection. Confidentiality of data was maintained, and the data was used only for this research study.
The study design was an analytical quantitative observational cross-sectional study from December 2017 to January 2018. We targeted Saudi females who were pregnant, had previously been pregnant, and had delivered and who attended different clinics at KKUH, which included medicine, surgery, obstetrics and gynecology (OB/GYN), dermatology, phlebotomy, and lastly, the primary care clinic.
Sample size calculation was done using an online tool (http://www.raosoft.com/). Using a 25% prevalence, a 4% margin of error, and a 95% confidence level, the calculated sample size was 441. However, the authors aimed to increase the number of participants to 540 to compensate for missing data and non-response. However, we were only able to collect 524 responses.
Convenient sampling based on different times from different female clinics was used as the sampling method. All Saudi women from the age of 16 years old and above who were previously or currently married were included. The questionnaire had 24 questions which were prepared in English and Arabic based on a literature search to answer our objectives by the mutual efforts of all authors (see Appendix). The questionnaire was developed by the authors after a thorough review of the literature and was translated into Arabic. Questions were closed-ended, open-ended, and some had binary answers (yes/no). Data collectors were trained in the use of the questionnaire. Participants were given a self-administered questionnaire.
Data were analyzed using the Statistical Package for Social Sciences (SPSS), version 21 (IBM SPSS Statistics, Armonk, NY). Descriptive statistics that were used included the mean, standard deviation, frequencies, and percentages. Chi-square and student t-test for independent samples were used for bivariate analysis. A pvalue of < 0.05 and 95% confidence intervals were used to report the statistical significance and precision of results.

Results
Of the 524 study participants, the ages varied widely, but the frequency was the highest in women aged > 50 (20.4%) and the lowest in the ones aged < 20 (1.1%). Housewives held the highest rate amongst other occupations, teachers came in second place, and there was a variable degree in other occupations. In regard to marital status, (88.5%) of the women were married and the rest were either divorced or widows. Having an income status of (5000 -10,000 Saudi Riyal (SR)) was represented in approximately 50% of our sample size, and only 5% had ≥ 20,000 SR. An overweight, Class I obesity, and normal weight body mass index (BMI) were ranked highest to lowest with percentages of 27.1%, 21.4%, and 18.1%, respectively. Many of the women in our study had a bachelor's degree, which represented as many as 44% of the total sample. Sociodemographic variables are shown in Table 1. However, of all of the participants, 32.6% of women underwent C-section and 67.4% of women had a normal delivery.

Social demographic N (%)
Age <  There was no association between BMI, the highest level of education, marital status, income status, and the mode of delivery. On the other hand, a noteworthy association between categories of occupation and csection was found. This might indicate that poor physical activity is related to C-sections. Also, women who were older in age had a significant association between their ages and C-section delivery ( Table 2).  Further tests for significance were done. A statistical significance was found between the number of children and the method of delivery. There was also statistical significance in the age when delivering the first child, while there was no statistical significance in the number of normal births or stillbirths (

CI: confidence interval
Both groups of women who underwent vaginal delivery (64.4%) and C-section (35.6%) preferred the doctor to be the one who makes the decision regarding the mode of delivery. They believed that women in our society preferred vaginal delivery to a C-section. Also, the answers indicated that vaginal delivery had fewer complications for the mother. Both groups of women who underwent C-section and vaginal delivery sometimes encountered women who preferred to deliver by C-section. They also believed that our community is moderately aware of the C-section complications with a percentage of 30.5% and 69.5%, respectively ( Table 4).

TABLE 4: Association of the Perceptual Study Variables with the Mode of Delivery
We concluded that malpresentation was the most common medical indication with an overall percentage of 25%, which is a quarter of the whole sample we distributed the data amongst. Pelvic organ prolapse, which has the least percentage of only 0.6%, indicates that it is not an important indication ( Table 5).

Discussion
In 1998, the prevalence of Australian women who gave birth by C-section was 21%, which was increased to 30.9% in 2007 [7]. In Egypt, the overall rate of delivery by C-section was 47.25%, which is higher than other rates quoted across the globe, both in developed and developing countries [8]. C-section reached about 10% of total births in Saudi Arabia and approximately reaching 20% in tertiary centers. The overall C-section rate increased from 10.6% in 1997 to 19.1% in 2006, corresponding to an 80.2% increase [5]. Over the last 20 years, a steady increase in the C-section delivery rate was observed at King Abdulaziz Medical City, Riyadh, Saudi Arabia [9]. C-section delivery rate advanced from 8% to 21% between the years 1993 and 2013. Our study shows that out of 524 study participants, 32.6% of women underwent a C-section. The occupation was significantly associated with C-section when compared with other variables. Knowing which occupation has higher rates of C-section may suggest other associated factors, such as physical activity, as some occupations may involve more physical activity than others. The rates of C-section vary from nation to nation. Saudi Arabia can be considered to have a bit higher rates of C-sections. The rates are acceptable in the United States, for example. One study showed that 11.6% had a non-indicated C-section, while 14.2% were indicated, and the rest underwent normal vaginal delivery [10]. The countries of South and Southeast Asia have different rates of C-section ranging from 1.51% to 58.54% [11]. The Maldives had the highest C-section rates (31.78%) based on institutional and non-institutional births, while Bangladesh had the highest rates (58.54%) based on institutional births. In Pakistan, one study reported a prevalence of 44.8%, of which 41.4% were elective C-sections [12]. In the same study, those who were nulliparous and done C-section represented 30%, this can be a warning sign since that currently the most common indication in was previous C-sections, accounting for 30.9%. On the other hand, our results suggest that the rate of Csection in Saudi Arabia are to be reviewed and to educate both patients and the treating doctors to include counseling about normal vaginal delivery for all elective C-section patients, if possible.
The imitations of our study were that our study design is cross-sectional and, therefore, we are only able to suggest associations rather than causal relationships. The sample subjects were from one public hospital (KKUH) exclusively, which limits the generalizability of our findings. The reliability of the questionnaire should be reassessed. These limitations could be overcome by repeating the same study as a cohort (prospective or retrospective). Also, widening the sample subjects to include participants from both private and public hospitals will lead to more confident generalization. Further studies should be conducted to investigate the high prevalence of malpresentation. Since we concluded that in the perception of our study subjects, the majority of our community were unaware of C-section complications, awareness campaigns should be conducted. Our study aimed to identify the prevalence of C-sections and understand the associated factors that influence a woman's choice to undergo that procedure. Filling the gap of knowledge about this issue should provide the basis for further research in order to solve the problem of increasing Csections. A reduction in rates is necessary since it has been reported that vaginal delivery is safer than Csection delivery concerning maternal mortality. Reducing the rate of an unnecessary C-section will lower its associated complications. Our future direction is to investigate the prevalence of C-section in private hospitals in Riyadh and compare them with our results at KKUH.

Conclusions
We found that the prevalence of Saudi women attending KKUH who underwent a C-section was 32.6%. Medical indications to undergo C-sections in comparison to the non-medical ones were higher. Malpresentation is the most common medical indication, with an overall percentage of 25%. Further studies should be conducted to investigate the high prevalence of malpresentation, as well as widening the spectrum of Saudi females included, such as those from private hospitals. We also recommend that awareness campaigns should be conducted since the majority of our community were unaware of C-section complications.