October 2007 - Volume 1, Issue 5

CHARACTERISTICS OF DELIVERIES AT A MATERNITY HOSPITAL: A SAMPLE FROM TURKEY

Gusun Bayraktar, MD, Assistant Doctor; Department of Family Medicine, Uludag University School of Medicine, Bursa, Turkey Ganime Sadikoglu, MD, Assistant Professor; Department of Family Medicine, Uludag University School of Medicine, Bursa, Turkey Alis Ozcakir, MD, Assistant Professor; Department of Family Medicine, Uludag University School of Medicine, Bursa, Turkey Sengül Cangür; Researcher; Department of Biostatistics, Uludag University School of Medicine, Bursa, Turkey Serhat Tatlikazan, MD, Specialist; Zubeyde Hanim Maternity Hospital,Bursa,Turkey Nazan Bilgel, MD, Professor; Department of Family Medicine, Uludag University School of Medicine, Bursa, Turkey Correspondence: Ganime Sadikoglu, MD Assistant Professor; Department of Family Medicine, Uludag University School of Medicine, Gorukle Campus, 16059, Gorukle, Bursa, Turkey. Tel: 0 224 2950000 Fax: 0224 2341172 E-mail: ganimes@uludag.edu.tr

ABSTRACT Introduction: The planning of the birthplace is considered as important as the pregnancy period. To be aware of the factors that have a strong effect on the preference of the maternity hospitals plays an important role in this planning. The aim of this study is to define the socio-demographic traits, birth forms and the prenatal-antenatal care rates of women who preferred Zubeyde Hanim Maternity Hospital. Methods: This study focuses on 500 pregnant women who applied to Zubeyde Hanim Maternity Hospital between July 2005 and September 2005. The data has been obtained by the investigators who filled the survey forms, which were prepared by a research group, by way of face to face interview. For the statistical measurements SPSS 9.01 program was used. Results: The average age of the study group was defined as 25.5 ± 5.2. 80.4% of women were from the town centre of Bursa, 18.4% were from small towns of Bursa and the other 1.2% were from other neighboring cities. When the women in the study group were examined according to their education, it became clear that 65.1% were primary school graduates, 22.2% high school graduates, 7% uneducated and 5.6% higher educated. Whilst 87.8% of women were housewives, just 12.2% were working (p<0.001). The birth form showed 58.4% normal spontaneous birth and 41.6% caesarian operations. Although 56.3% of women who had a caesarian operation were primary school graduates, 60.7% of higher educated women preferred a caesarian operation. It was observed that the caesarian operation rates, age of first birth and prenatal-antenatal care rates increased and the number of children decreased according to the education level. Discussion: Pregnancy and birth are periods during which women most require a health centre. The women's age, education level and socio-economic factors play an important role in preference of these health centres. The primary care physician is the most important person who can examine the socio-demographic traits and preferences of the woman and can assist with the planning of the consultations during the pregnancy period and birth.

Key words: Maternity hospital, Socio demographic, Pregnancy

INTRODUCTION

To contribute to personal, familial and public health, to protect and improve maternal health at all stages of life, to resolve problems related with women's health, maternal and children's health and also reproductive health are important duties of family physicians in primary health care (1).
The problems experienced by the mother before or during pregnancy and existent risk factors affect the unborn baby. It is important for the unborn baby to become a healthy individual and to detect the risk factors of the mother and the problems that arise before or during pregnancy which may cause symptoms or not (2). By consulting their physicians, mothers must find out whether they carry risk factors and if so they must learn how their pregnancy, labor and babies will be affected and what to pay attention to. This can be only possible if mothers comprehend the importance of prenatal and antenatal care. Several factors such as maternal age during pregnancy, occupation, inhabitation, socio-economic and educational status can play a role in this comprehension. Also these factors may be effective for determining the appropriate delivery method (3).

Therefore family physicians are responsible for determining every risk profile that can be experienced during pregnancy and follow-up within their responsibility scope. Towards the determination of the risk factors during pregnancy, planning the place of labor is important. In light of this knowledge. It can be observed that in our country some studies were performed about delivery methods, reasons for caesarean delivery and prenatal-antenatal care; also socio-demographic characteristics of pregnant women living in rural areas need to be investigated. Saka et al evaluated the socio-demographic characteristics and smoking status of pregnant women who gave birth at Diyarbakir Maternity Hospital, while Ozkaya wanted to show the annual birth rates and caesarean delivery indications in Demirel University Obstetrics and Gynecology Clinic (4,5). Bozkurt et al investigated the situation of receiving prenatal, natal and postnatal health care of married women aged 15-49 years, who were admitted to primary health care centers for any reason in Gaziantep, and also the factors affecting this situation6. However neither study could be found in literature that evaluates socio-demographic characteristics of pregnant women, delivery methods and prenatal-antenatal care status all together.

In this study defining the prenatal-antenatal care ratio and delivery methods of women who preferred Zubeyde Hanim Maternity Hospital, as well as socio-demographic features which affect these situations is aimed.

MATERIAL AND METHOD

500 pregnant women were included to this study, who were admitted to Zubeyde Hanim Maternity Hospital in Bursa for delivery between June 2005 and September 2005. The study is based on questionnaire method. A questionnaire form including 23 questions relating to socio-demographic features, as well as characteristics of previous labors, prenatal-antenatal follow-up and delivery methods was prepared by investigators. In the course of the study, the method in which the research assistant who worked in the study group interviews with the pregnant woman, one to one interview was preferred. In this manner it was ensured that collecting data was more reliable. Analysis using descriptive statistics of data was performed using SPSS 9.01 computer software. Depending on characteristics of variables Pearson chi-square test and Fisher exact chi-square test were performed for categorical variables, while Kruskal-Wallis and Mann-Whitney U test of non-parametric tests were used to compare the groups for quantitative variables. Correlation analysis was performed to define the statistical significance of the relationship between quantitative variables.

RESULTS

The mean age of pregnant women admitted to Bursa Zubeyde Hanim Maternity Hospital was 25.5±5.23. Of the cases 80.4% resided in Bursa, 18.4 in boroughs and villages of Bursa and 1.2% resided in other cities. 87.8% of the women were housewives while 12.2% were working at various jobs. Mean age of first delivery was detected as 22.5±3.81, mean pregnancy duration was 38.9±1.94 weeks and monthly income was 715.17±584.71 YTL. If the distribution of the women in the study group according to their educational status is examined it can be seen that 65.1% of the women were primary school graduated, 22.2% were high school graduated, 5.6% were college graduated and 7.1% were illiterate (Table 1).

56.2% of the cases gave birth to their first children; also 57.4% had no live children. During previous pregnancies 18.7% of participants had a history of abortion and/or curettage, 3.2% had a history of stillbirth and 1.4% had a history of giving birth to a baby with congenital abnormalities. Considering the type of the labor, 41.6% had a history of caesarean delivery while 58.4% had normal spontaneous vaginal delivery. 74.4% received prenatal-antenatal follow-up, whereas 25.6% did not receive this care.

There was a statistically significant difference between cities where cases resided and the history of a previous stillbirth (p<0.05) and prenatal-antenatal follow-up (p<0.05). The ratio of previous stillbirth was 2.8% and for prenatal-antenatal follow-up it was 74.9% in cases who resided in Bursa or its boroughs and villages, whereas the stillbirth ratio was 33.3% and prenatal-antenatal follow-up ratio was 20% in cases residing in other cities (Graph 1).

History of previous stillbirth and congenital anomaly with respect to the distribution of mean ages can be seen in Table 2. A statistically significant relationship was found between ages of the cases and the history of stillbirth and the history of congenital anomaly (p<0.05).

Correlation analysis revealed positive correlation between maternal age and total number of deliveries, also between maternal age and the number of abortions and/or curettages (r=0.597,p=0.00 and r=0.275,p=0.008 respectively); whereas there was a negative correlation between first pregnancy age and total number of deliveries (r=-0.210,p=0.00).

There was a statistical significance according to educational status and number of deliveries (p<0.001), first pregnancy age (p<0.001), number of live children (p<0.005), history of previous stillbirths (p<0.001), delivery methods and prenatal-antenatal follow-up (p<0.001). The relationship between educational status and mean number of deliveries, first pregnancy age and number of live children can be seen in Table 3.

There was a history of stillbirth in 20% of participants who were illiterate, 1.8% of those who were primary school graduated, 1.8% of those who were high school graduated and 3.5% of participants who were college graduated. Of the 64.7% of cases who were illiterate, 28% were primary school graduates and 12.8% were high school graduates and received no prenatal-antenatal follow-up care, whereas all college graduates received follow-up care. History of caesarean delivery existed in 48.6% of illiterates, 36% of primary school graduates, 51.4% of high school graduates and 60.7% of college graduates.

There was a statistical significance between occupation and prenatal-antenatal follow-up (p<0.05); while prenatal-antenatal follow-up ratio was 72.5% among housewives. It was 100% among working women.

DISCUSSION

Defining the features that mother candidates possess is required to prevent medical or obstetrical complications that can occur during pregnancy. It is also very important to make a risk analysis, appropriate follow-up and delivery planning for mother and baby, together with the family.

In our study it was observed that cases who were admitted to the maternity hospital from outside of Bursa had a higher rate of stillbirth but lower prenatal-antenatal follow-up ratio during their previous pregnancies (33.3% and 20% respectively). But it is also possible that stillbirth ratio of these cases is higher because most participants in this study are from Bursa and it's boroughs and villages, whereas the number of participants admitted from other cities was small and complication probability was higher in these cases because they didn't receive proper follow-up care.

Seven percent of the cases in our study were illiterate; whereas the ratio of illiterate pregnant women who gave birth at Diyarbakir Maternity Hospital between April 1997 and May 1997 was 54.6% in the study of Saka et al in which socio-demographic features and smoking status of pregnant women was investigated (4). Compared to our study this ratio seems too high; this difference in educational status could result from regional factors.

In the study of Ozkaya et al which investigated 1502 deliveries that took place at Suleyman Demirel University Obstetrics and Gynecology Clinic between years 1998-2002, the ratio of caesarean delivery was found to be 53.7% and normal vaginal delivery ratio was found to be 46.3% (5). The results of this study seem to be similar to the results of our study. However in a study that examines 5128 deliveries carried out in Dicle University Medical Faculty of Obstetrics and Gynecology, Clinic between years 1995-1999 retrospectively, the ratio of caesarean deliveries was 29.7% (7); also in another retrospective study that investigated 32,699 deliveries carried out in Kayseri Maternity Hospital between years 1998-2001, the ratio of caesarean deliveries was reported as 10.15% (8). In the study which investigated the methods of delivery performed during the last six years in SSK Ege Maternity Hospital, the ratio of caesarean deliveries was reported as 19.24%, whereas vaginal delivery ratio was reported as 80.76% (9). When we compare these results with our study it is seen that caesarean ratios are lower in these three studies. This could be due to the higher number of cases or because number of deliveries and delivery methods could be defined.

Mean ages of the cases who have a history of stillbirth or giving birth to a baby with congenital anomaly seem to be higher than cases who didn't have such a history. This may be related to the fact that women who have such a history get pregnant at an earlier age and they have a higher number of pregnancies.

In the study performed by Bozkurt et al which evaluated the prenatal, natal and postnatal care status of 500 married women aged 15-49 years who were admitted to primary health care centers in Gaziantep for any reason between March 1999-April 1999 and also the factors affecting this situation; it was found that 24.1% of the cases didn't receive any prenatal care during their last pregnancies and 10.2% of the cases gave birth to their children without help of any medical staff in their last pregnancies. This situation is thought to be due to living in rural areas, low educational status of woman and their spouse or lack of social security (6). In the study performed at a maternity & children's hospital in Adelaide, South Australia where 2000 women participated in the study, were of the same opinion that caesarean is an easy and appropriate method for delivery; but this situation was determined as independent from variables like age and educational status (10). In our study three-quarters of the cases seem to have received prenatal-antenatal follow-up. As educational levels rise, the mean number of deliveries and number of live children decreases but mean first pregnancy age increases; however as educational level decreases the ratio of prenatal-antenatal follow-up also decreases but history of stillbirth in previous pregnancies increases. 64.7% of illiterates received no prenatal-antenatal follow-up during their pregnancies and 20% of them had a history of stillbirth. As educational level raised the ratio of caesarean deliveries also increased. However caesarean delivery ratio of illiterate women was also high. Inadequate prenatal-antenatal follow-up and pregnancy complications, which probably occurred due to this situation could be effective for the high caesarean ratio of illiterate women. Higher caesarean ratio in participants with higher educational levels could be due to the increase in first pregnancy age or a social indication for caesarean decided between patient and physician. When housewives and working women were compared according to prenatal-antenatal follow-up status, it was found that all of the housewives had received prenatal-antenatal follow-up, whereas 72.5% of working women received such care. Low educational level of housewives could play a role in detecting this lower ratio of prenatal-antenatal follow-up.

In the study which investigated the demographical factors and factors that affect the fertility of 15-49 years aged married women in Malatya Yesilyurt, 20.5% of the cases were illiterate, 6% were literate, 58% were primary school graduated, 15.5% of cases were graduated from middle school or higher and mean first pregnancy age was 19.1±3.1. High delivery rate was evaluated in this study and it was observed that the number of live children negatively by first pregnancy age was younger than 20 years and educational status being primary school graduate or lower positively affected this situation (11) In our study, although mean first pregnancy age was higher than 20, number of deliveries was high in cases who had low educational levels. This result can be due to the fact that education makes women conscious of contraceptive methods and so they accept them.

Mean ages of cases with caesarean delivery history being low can be attributed to the high proportion of cases being housewives, low educational level and inadequate prenatal-antenatal follow-up.

As a result, pregnancy and labor are periods in which women need health care centers most. Age, educational status and socioeconomic factors are determinative for preferring these health care centers. In our study it was observed that inhabitation, occupational status and educational level are effective for receiving prenatal-antenatal care; additionally age of the mother, inhabitation and educational level affect the history of stillbirth during previous pregnancies; and finally educational level influences the selection of delivery method.
The family physician is the most important person who can help women by organizing the required consultations in the pregnancy period and by planning the labor, after evaluating her socio-demographic features and choices.

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