Evolution in caesarean section practices in North Kivu: Impact of caregiver training.

INTRODUCTION: A caesarean section is a major obstetric procedure that can save the life of mother and child. Its purpose is to protect the mother's health from the complications of childbirth and to protect the baby's health. In sub-Saharan Africa (SSA), there are major inequalities in access to caesarean sections and significant variations in practices to determine the indications for the procedure. Periodic analyses of maternal deaths have shown that more than half of maternal and new born deaths are due to suboptimal care and are therefore potentially preventable. The objective of our study is to assess the impact of health staff training under the PADISS project (to support the health system's integrated development) on the quality of CS procedures in North Kivu, by comparing two periods.
MATERIAL AND METHODS: The populations compared were recruited from the referral hospitals in North Kivu, DRC (Democratic Republic of Congo). The first (group 1) was made up of patient files studied retrospectively for the period from 01/11/2013 to 01/01/2016. The second group (group 2), studied prospectively, comprised patient files from June 2019 to January 2020. Obstetric, maternal and foetal data were compared. Statistical analyses were performed using STATA/IC 15.0 for Windows. Univariate and multiple logistic regression was performed to determine which characteristics are associated with maternal and perinatal morbidity and mortality. A p value < 0.05 was considered statistically significant.
RESULTS: CS frequency was approximately 17% in both study periods. We observed a CS frequency of about 34% at North Kivu provincial hospital for the two populations studied. The main indications for CS were dystocia, foetal distress and scarred uterus for both populations. In the population studied prospectively, after the implementation of health staff training, there were fewer incidence rate of dystocia, foetal distress and neonatal death, a more complete patient record, shorter hospital stay, and fewer blood transfusions but more incidence rate of scarred uterus, post-operative complications and low birth weight. Intervention had no statistically significant impact on low birth weight (OR = 1.9, p = 0.13), on neonatal mortality (OR = 0.69, p = 0.21).
CONCLUSION: Our study shows a decrease in neonatal deaths, dystocia and foetal distress, but an increase in post-operative complications, maternal deaths and cases of scarred uterus and low birth weight. However, multiple logistic regression did no support the conclusion.

Introduction

A caesarean section is a major obstetric procedure that can save the life of mother and child [1]. Its purpose is to protect the mother’s health from the complications of labour (uterine rupture, fistulae, perineal problems and incontinence, postpartum hemorrhage, placenta praevia) or to protect the baby’s health (stillbirth, asphyxia, neurological damage). In sub-Saharan Africa (SSA), there are major inequalities in access to caesarean sections and significant variations in practices to determine the indications for the procedure. On the one hand, financial, geographic and cultural barriers deprive women of a procedure that could save their lives. On the other hand, the growing use of caesarean section with no medical indication, in a context of poor quality of care, causes iatrogenic and preventable excess morbidity and mortality [2, 3].Worldwide, approximately 22.9 million caesarean sections (CS) are performed every year, primarily to save the life of the mother and/or newborn infant [1]. However, with nearly 2 deaths in 1000 live births, the global post-CS neonatal mortality rate is three times higher than the vaginal delivery mortality rate [4]. Nearly 300,000 women die every year as a result of a pregnancy, a caesarean or vaginal delivery [5]. Of these maternal deaths, 99% occur in developing countries [5]. In sub-Saharan African (SSA), 8.8% of deliveries are by CS [6], which is in line with the 10 to 15% recommended by the World Health Organization (WHO) [7]. However, intrapartum mortality in SSA accounts for 73% of neonatal deaths worldwide [8]. In the Democratic Republic of Congo (DRC), the latest demographic and health surveys show that the CS rate rose from 4% in 2007 [9] to 5% in 2013 [9]. A study conducted in Goma (North Kivu) between 2013 and 2016 in four referral hospitals reported a caesarean rate of 16%, that the majority of CS were performed as an emergency and under loco regional anaesthesia, and that the perinatal risk was higher when the CS was performed as an emergency and under loco regional anaesthesia [10]. Several risk factors which increase maternal and perinatal morbidity and mortality in the intra- and post-CS period have been identified, in particular the shortage of qualified health staff, lack of health staff training, inadequate medical infrastructure, difficulties in performing the CS in due time when women need one, as well as the high cost of the procedure in relation to the population’s income [11]. Periodic analyses of maternal deaths in the United Kingdom have shown that more than half of maternal and neonatal deaths were due to suboptimal care and that they were therefore potentially preventable [12]. The authors highlight not only the inability of certain health staff to identify and treat obstetric emergencies, and gaps in technical skills, but also significant problems as regards interpersonal and interdisciplinary communication. In the United States, the Institute of Medicine has published two reports that highlight the importance of improving the quality of healthcare [13, 14] and recommend establishing training programmes for individuals and teams that incorporate methods such as simulation, which has proven effective in other fields of medicine. A programme carried out recently in Tanzania, showed the potential of simulation for decreasing the occurrence of obstetric complications in countries with few material resources, improving particularly the management of the third stage of labour [15]. The objective of our study is to assess the impact of the health staff training provided under the PADISS project (to support the health system’s integrated development) on the quality of CS procedures in North Kivu province.

Material and methods

Population

The first, baseline population was recruited from referral hospitals in the city of Goma from the period 01/11/2013 to 01/01/2016 (group 1). It is a retrospective, descriptive and analytical study concerning all CS performed across all deliveries that occurred during the period under study [10]. Twin pregnancies were excluded from the study. The medical staffs in each hospital were capable of performing a CS. A data collection form was designed. Data collection was carried out by a team of investigators made up of doctors and midwives in these maternity units. The sources of information were the delivery record, partograph, surgical reports and neonatal records. The sociodemographic parameters (maternal age, marital status, level of education, ethnicity, occupation, primary residence, weight, height), medical and surgical history, obstetric environment (antenatal monitoring), and maternal and perinatal morbidity and mortality (complications and outcome) were analyzed.

The data collection was anonymous for the retrospective study after the agreement of the provincial authority. For the prospective study, consent was verbal, free and informed after explaining the objectives of this research.

Intervention

After analysis of our retrospective study, cesarean section was not a factor in reducing maternal and perinatal morbidity and mortality, hence the benefit of improving working conditions at the level of referral centers, transfert conditions, basic infrastructure and caregiver training.

Following these findings, specific training was given to the local health staff. The training was based around theory and clinical activities that were carried out during our various visits in order to increase the skills of the gynaecologists, obstetricians and midwives in the different health zones in North Kivu. This training was delivered by the team of gynaecologists, obstetricians, paediatricians, anaesthetists, hygienists, midwives and theatre nurses at Erasme hospital in Brussels as part of the PADISS project. For the theory activities, several seminars were held on the pedagogical elements with a continuing education frame of reference, on the organisation of clinical audits, the preparation of treatment protocols with all the gynaecologists and members of the provincial health department (DPS), the preparation of different themes for the continuing education, such as gestational hypertension, gestational diabetes, the management of antenatal and post-partum hemorrhage, caesarean section and its alternatives, echography in gynaecology and obstetrics, antenatal consultations, monitoring during labour, the use of obstetric manoeuvres, hospital hygiene, the maintenance of medical files, and neonatal care. The gynaecologists, obstetricians, midwives and maternity-paediatric nurses from these various health zones attended these non-certificate courses on a daily basis.

For the clinical activities, the objective was to provide technical support to medical and midwifery trainers, establish the pedagogical method for the training linking the frame of reference and the different activities, and carry out individual skills assessments. The clinical activities were based around ward rounds with trainee doctors and by the provincial trainer, participation in gynaecological and obstetrical consultations, the approach to paraclinical tests taking into account the situation on the ground, assistance in the operating theatre and delivery room, as well as teaching obstetric maneuvers to all health staff using simulations on a manikin. A second population (group 2) was therefore selected prospectively in order to assess the benefit of the training provided. The training started from February 2016 until March 2020. The various teams of gynecologists, pediatricians, anesthesiologists, health doctors, midwives, nurses in the operating room had carried out several missions in the field. Each mission was for an average duration of 10 days, 8 hours of theoretical and practical training per day.

The second group was recruited from the same hospitals in Goma for the period from June 2019 to January 2020 (group 2). This was a prospective, analytical, cross-disciplinary study concerning all CSs performed across all deliveries (2094) that occurred during the period under study. Twin pregnancies were excluded from the study. All the women who had a CS in the hospitals were included exhaustively in the study. Data collection was carried out by a team of investigators made up of doctors and midwives in these maternity units. The sources of information were the delivery record, partograph, surgical reports and neonatal records. The sociodemographic parameters (maternal age, marital status, level of education, ethnicity, occupation, primary residence, weight, height), medical and surgical history, obstetric environment (antenatal visits), and maternal and perinatal morbidity and mortality (complications and outcome) were analyzed and compared with group 1.

Statistical analysis

The findings are reported as a percentage for the categorical variables, as average and standard deviation (SD) or median and interquartile range [25%-75%] for the quantitative variables depending on their respective distribution, Gaussian or otherwise. The categorical variables were compared between the two groups using the Chi2 Pearson test, or Fisher’s exact test for a small sample. The quantitative variables were compared using the Mann Whitney test depending on their respective distribution, Gaussian or otherwise.

Univariate and multiple logistic regression was used to study the association between our variables (socio-demographic, medical and obstetric) and three other variables (low birth weight, neonatal mortality and post-operative complications). The variables with a high percentage of missing values were not included in the univariate analysis. The variables included in our multiple logistic regression model were selected according to the statistical association (p ≤ 0.05) with the result of the univariate analysis, and to the total number of cases. The odds ratios and their 95% confidence intervals were calculated using each variable coefficient (and standard errors) in the model. The significance of each coefficient was tested using the Wald test. The Hosmer and Lemeshow test was used to verify the model’s goodness of fit. A value of p < 0.05 was considered statistically significant. Statistical analyses were performed using STATA/IC 16.0 for Windows.

Ethic statement: The provincial health division of North-Kivu in the democratic Republic of Congo does not have an ethics commitee. Authorization to conduct this research was obtained by the same provincial authority that had waived informed consent for the retrospective study. The data in this retrospective study was anonymised.

For the prospective study, patients had given their informed verbal consent for data from their medical records to be used for research.

Results

CS frequency and sociodemographic characteristics

The CS frequency in the study prior to our intervention (group 1) was 16.2%, and after our intervention (group 2), the CS frequency was 17%. This difference is not statistically significant.

The highest frequency at approximately 34% was seen at the North Kivu provincial hospital in both groups. Table 1 shows the socio-demographic characteristics of the women whose files were included in the study. Overall, the women who had undergone a CS in the study prior to our intervention (group 1) were mostly married, housewives, who had been to secondary school, were of Nande ethnicity, and living in the vicinity of the medical facility that performed the CS (Table 1).Our study showed more single women, with a lower level of education, and farmers living in rural areas far from the hospital in the health zone of their village of origin in group 2 than in group 1.

Table 1

Socio-demographic data.

	No Intervention (n = 694)	Intervention (n = 356)	p-value
Woman’s age (years) *			0.81
	26.8 (6.2)	26.7 (5.7)
Marital status			0.001
Married	604 (89.1)	281 (81.5)
Single	74 (10.9)	64 (18.5)
Woman’s level of education			< 0.0001
None	82 (12.4)	100 (28.7)
Primary	62 (9.4)	93 (26.7)
Secondary	301 (45.4)	125 (35.9)
Higher	87 (13.1)	29 (8.3)
Other	131 (19.8)	1 (0.3)
Ethnicity#			< 0.0001
Nande	165 (38.6)	162 (46.4)
Hunde	59 (13.8)	43 (12.3)
Havu	13 (3.0)	15 (4.3)
Shi	47 (11.0)	32 (9.2)
Hutu	33 (7.7)	52 (14.9)
Other	110 (25.8)	45 (12.9)
Woman’s occupation			< 0.0001
Housewife	526 (77.2)	193 (54.7)
Civil servant	20 (2.9)	11 (3.1)
Student	24 (3.5)	4 (1.1)
Liberal profession	16 (2.4)	17 (4.8)
Farmer	9 (1.3)	91 (25.8)
Other	86 (12.6)	37 (10.5)
Primaryresidence			< 0.0001
Urban area	617 (92.8)	220 (61.8)
Rural area	48 (7.2)	136 (38.2)
Hospital in the health zone of the woman’s village of origin			< 0.0001
Yes	405 (62.8)	160 (48.3)
No	240 (37.2)	171 (51.7)

*mean (SD)

#38.5% missing

Medical data

In group 2, the height and weight of the women was complete and properly recorded in the files and this made it possible to calculate the BMI (body mass index) more accurately. In group 2, primigravidas underwent fewer CSs, and the CS was mostly performed on women who had a history of two or more CS. There was a higher number of women who had been to four antenatal visits or more in group 2 (Table 2). In group 2, urine tests during the antenatal visits highlighted less albumin, less sugar and fewer urinary tract infections in relation to group 1 (Table 2). Blood tests at the antenatal visits in group 2 showed few cases of malaria, but this was not investigated in the majority of patients. Toxoplasmosis, cytomegalovirus and rubella status was not widely investigated in either group. The majority of women in both study groups were HIV negative (Table 2).

Table 2

Medical data.

	No Intervention (n = 694)	Intervention (n = 356)	p-value
BMI (kg/m2)*			< 0.0001
	28.9 (4.7)	27.1 (4.0)
History of hypertension			< 0.0001
No	175 (87.1)	287 (96.3)
Yes	26 (17.9)	11 (3.7)
Family history of hypertension			< 0.0001
No	113 (75.8)	270 (92.1)
Yes	36 (24.2)	23 (7.9)
History of diabetes			0.28
No	196 (97.5)	295 (99)
Yes	5 (2.5)	3 (1)
Family history of diabetes			0.1
No	130 (87.2)	270 (92.2)
Yes	19 (12.8)	23 (7.8)
Parity			< 0.0001
0	210 (30.6)	65 (18.2)
1–3	319 (46.4)	195 (54.8)
≥ 4	158 (23)	96 (27)
Abortion			0.07
0	519 (78.9)	286 (81)
1	91 (12.8)	54 (15.3)
≥ 2	48 (7.3)	13 (3.7)
Number of previous caesareans			< 0.0001
0	304 (52.4)	104 (32)
1	154 (26.6)	88 (27.1)
≥ 2	122 (21)	133 (40.9)
No. of antenatal visits during current pregnancy			0.02
0	16 (2.7)	5 (1.5)
1	26 (4.4)	13 (4.0)
2	69 (11.6)	22 (6.8)
3	188 (31.7)	89 (27.6)
≥ 4	294 (49.6)	193 (59.9)
Albuminuria			< 0.0001
Yes	82 (13.6)	8 (2.3)
No	202 (33.4)	211 (60.1)
Not investigated	320 (53)	132 (37.6)
Sugar in the urine			< 0.0001
Yes	39 (6.5)	1 (0.3)
No	181 (30.3)	211 (59.9)
Not investigated	378 (63.2)	140 (39.8)
Urine infection			< 0.0001
Yes	79 (29.4)	51 (14.5)
No	249 (40.9)	203 (57.7)
Not investigated	180 (29.6)	98 (27.8)
Presence of malaria parasite			< 0.0001
Yes	68 (11.3)	18 (5.1)
No	323 (23.6)	139 (39.6)
Not investigated	211 (35.1)	194 (55.3)
HIV			0.89
Yes	7 (1.1)	4 (1.2)
No	440 (72.5)	255 (73.9)
Not investigated	160 (26.4)	86 (24.9)
Rubella			0.003
Yes	1 (0.2)	1 (0.3)
No	35 (5.9)	40 (11.5)
Not investigated	561 (94)	307 (88.2)
Toxoplasmosis			< 0.0001
Positive	2 (0.3)	0
Negative	12 (2.0)	24 (6.9)
Not investigated	590 (97.7)	323 (93.1)
CMV			0.002
Positive	0	1 (0.3)
Negative	12 (2.0)	20 (5.8)
Not investigated	591 (98)	324 (93.9)

Obstetric characteristics

The majority of these CSs were performed as emergencies and for cephalic presentation of the foetus, and loco regional anaesthesia was the most used in both groups. However, many more patients had been referred before onset of labour and during labour in group 2 than in group 1. There were more spontaneous and fewer induced labours, and more CSs performed before onset of labour in group 2 than in group 1 (Table 3). The main indications for CS in both groups were dystocia, scarred uterus and foetal distress. In group 2, there were fewer cases of dystocia and foetal distress, but more cases of scarred uterus, a more comprehensive operating protocol, more transverse incisions, fewer blood transfusions, and the CS was performed more often by a gynaecologist than in group 1 (Table 3).

Table 3

Obstetric data.

	No Intervention (n = 694)	Intervention (n = 356)	p-value
Type of admission			0.9
Normal prior to onset of labour	260 (38.3)	133 (37.9)
Emergency during labour	419 (61.7)	218 (62.1)
Mode of admission			< 0.0001
Referral prior to onset of labour	5 (0.7)	149 (42.1)
Referral during labour	131 (19.3)	186 (52.5)
Personal decision prior to onset of labour	139 (20.5)	7 (2.0)
Personal decision during labour	403 (59.4)	12 (3.4)
If transfer, facility situation	n = 144	n = 332	0.06
Facility in the hospital’s health zone	87 (60.4)	169 (50.9)
Facility outside the hospital’s health zone	57 (39.6)	163 (49.1)
Fundal height in centimetres before caesarean			0.01
	32.5 (3.2)	33.1 (3.6)
Presentation of the foetus			0.01
Cephalic	611 (90.3)	314 (89.2)
Breech	53 (7.8)	20 (5.7)
Transverse lie	8 (1.2)	15 (4.3)
Other	5 (0.7)	3 (0.9)
Onset of labour			< 0.0001
Spontaneous	517 (76.8)	282 (80.8)
Induced	124 (18.4)	11 (3.1)
Caesarean before labour	32 (4.8)	56 (16.1)
Type of primary anaesthesia			0.002
loco-regional	429 (62.8)	255 (72.4)
general	254 (37.2)	97 (27.6)
Type of secondary anaesthesia			0.004
No	625 (97)	319 (92.5)
General	9 (1.4)	14 (4.1)
Loco-regional	10 (1.6)	12 (3.5)
Pre-operative indication for Caesarean 1
Pelvic anomaly
No	568 (82.4)	316 (91.9)	< 0.0001
Yes	121 (17.6)	28 (8.1)
Scarred uterus
No	640 (92.9)	316 (91.9)	0.55
Yes	49 (7.1)	28 (8.1)
Foetal distress
No	597 (86.7)	309 (89.8)	0.14
Yes	92 (13.3)	35 (10.2)
Placenta praevia
No	663 (96.2)	334 (97.1)	0.47
Yes	26 (3.8)	10 (2.9)
Other
No	433 (62.8)	235 (68.3)	0.08
Yes	256 (37.2)	109 (31.7)
Post-operative indication for Caesarean 1
Pelvic anomaly
No	564 (82.9)	280 (89.7)	0.005
Yes	116 (17.1)	32 (10.3)
Scarred uterus
No	532 (78.2)	201 (64.6)	< 0.0001
Yes	148 (21.8)	110 (35.4)
Functional dystocia
No	636 (93.5)	287 (92.3)	0.47
Yes	44 (6.5)	24 (7.7)
Foetal distress
No	582 (85.6)	277 (89.4)	0.11
Yes	98 (14.4)	33 (10.6)
Placenta praevia
No	655 (96.3)	301 (97.1)	0.54
Yes	25 (3.7)	9 (2.9)
Other
No	421 (61.9)	207 (66.6)	0.16
Yes	259 (38.1)	104 (33.4)
Operating protocol in the woman’s file			< 0.0001
Complete, and mentions the procedure in detail along with all post-operative instructions	452 (66.8)	293 (86.2)
Incomplete, only mentions the procedure but in detail	22 (3.3)	31 (9.1)
Incomplete, only gives a summary of the procedure	196 (28.9)	16 (4.7)
None	7 (1.0)	0.0
Type of incision			< 0.0001
No	18 (2.6)	5 (1.4)
Transverse	296 (42.7)	200 (56.2)
Midline	380 (54.7)	151 (42.4)
Transfusion performed			0.04
Yes	37 (5.7)	10 (2.8)
No	609 (94.3)	343 (97.2)
Qualification of the person who performed the caesarean			0.015
General practitioner	631 (93.8)	320 (91.7)
Surgeon	10 (1.5)	1 (0.3)
Gynaecologist	32 (4.8)	26 (7.5)
General nurse	0	2 (0.6)

Pregnancy outcomes

Our study shows more cases of low birth weight, more post-operative complications, more maternal deaths, lower perinatal mortality, shorter stays in hospital and more complete patient files in group 2 than in group 1 (Table 4).

Table 4

Pregnancy outcomes.

	No Intervention (n = 694)	Intervention (n = 356)	p-value
APGAR at 1 min			0.17
≥ 7	589 (86.9)	318 (89.8)
< 7	89 (13.1)	36 (10.2)
APGAR at 5 min			0.36
≥7	639 (94.4)	330 (93)
< 7	38 (5.6)	25 (7)
APGAR at 10 min			0.49
≥7	646 (95.4)	342 (96.3)
< 7	31 (4.6)	13 (3.7)
Baby’s birth weight in grams			0.02
≥ 2500g	553 (92.3)	309 (87.8)
< 2500 g	46 (7.7)	43 (12.2)
Intra-operative complications
No	653 (97.6)	338 (97.4)	0.84
Yes	16 (2.4)	9 (2.6)
Post-operative complications
No	651 (97.6)	16 (4.7)	< 0.0001
Yes	16 (2.4)	326 (95.3)
Mother’s outcome			0.046
Death	1 (0.15)	4 (1.2)
Discharged	674 (99.7)	337 (98.8)
Transferred	1 (0.15)	0
Infant’s outcome			0.04
Discharged	636 (94.1)	334 (96.8)
Macerated stillbirth	11 (1.6)	1 (0.3)
Fresh stillbirth	17 (2.5)	3 (0.9)
Unspecified stillbirth	2 (0.3)	3 (0.9)
Live birth but died within 24h	3 (0.4)	3 (0.9)
Transferred	7 (1.0)	1 (0.3)
Neonatal death
No	643 (95.1)	335 (97.1)	0.14
Yes	33 (4.9)	10 (2.9)
Total duration of stay in days			< 0.0001
	5 (5–7)	3 (3–7)
Patient’s file is complete			< 0.0001
Yes	360 (53)	249 (92.9)
No	319 (47)	19 (7.1)

Logistic regression

The association of risk factors for low birth weight is due to health staff training OR 1.7 (IC95% 1.1–2.6), primary residence (rural location) OR 2.4 (IC95% 1.5–3.8), type of admission OR 0.33 (IC95% 0.14–0.80), fundal height before CS OR 0.74 (IC95% 0.68–0.80), presentation of the foetus OR 2.1 (breech), OR 5.1 (other presentation), and type of anaesthesia, particularly general anaesthesia OR 1.7 (IC95% 1.1–2.6) (Table 5).

Table 5

Univariate and multiple logistic regression of the association of risk factors for low birth weight.

	OR (IC 95%)	p-value	aOR (IC 95%)	p-value
Intervention
No	1	0.02	1	0.13
Yes	1.7 (1.1–2.6)		1.9 (0.8–4.3)
Woman’s age in years	1.01 (0.97–1.05)	0.57
Marital status
Married	1	0.92
Single	1.03 (0.54–1.96)
Woman’s level of education
None	3.2 (0.91–11.4)	0.09
Primary	3.4 (0.95–12.0)
Secondary	2.9 (0.86–9.6)
Higher	1
Other	5.3 (1.5–18.4)
Woman’s occupation
Housewife	1	0.49
Job	1.2 (0.71–2.1)
Other	0.73 (0.34–1.57)
Primary residence
Urban area	1	< 0.0001	1	0.55
Rural area	2.4 (1.5–3.8)		1.2 (0.61–2.5)
Parity
0	1	0.93
1–3	1.1 (0.63–1.87)
≥ 4	1.1 (0.60–2.1)
Number of previous caesareans
0	1	0.49
1	0.80 (0.43–1.48)
≥2	1.2 (0.69–2.05)
Hospital in the health zone of the woman’s village of origin
Yes	1	0.37
No	1.2 (0.78–1.96)
Type of admission
Normal prior to onset of labour	1
Emergency during labour	0.24 (0.8–2.09)
Mode of admission
Referral prior to onset of labour	1	0.04	1	0.90
Referral during labour	0.69 (0.38–1.24)		0.85 (0.29–2.47)
Personal decision prior to onset of labour	0.33 (0.14–0.80)		0.96 (0.44–2.1)
Personal decision during labour	0.51 (0.28–0.93)		0.73 (0.30–1.79)
Fundal height in centimetres before caesarean		< 0.0001
	0.74 (0.68–0.80)		0.73 (0.67–0.80)	< 0.0001
Presentation of the foetus
Cephalic	1	0.0001	1	0.004
Breech	2.1 (1.04–4.4)		2.6 (1.15–5.91)
Other	5.1 (2.2–11.6)		4.1 (1.4–12.2)
Onset of labour
Spontaneous	1	0.35
Induced	0.9 (0.43–1.74)
Caesarean before labour	1.6 (0.80–3.15)
Type of primary anaesthesia
loco-regional	1	0.03	1	0.01
general	1.7 (1.1–2.6)		1.6 (0.86–2.8)
Pelvic anomaly
No	1	0.08
yes	0.50 (0.22–1.10)
Post-operative indication for Caesarean 1
Pelvic anomaly
No	1	0.08
yes	0.49 (0.22–1.09)
Scarred uterus
No	1	0.06
yes	0.58 (0.32–1.03)

The association of risk factors for neonatal mortality were non-cephalic presentation of the foetus OR 1.2, 4.4, the use of general anaesthesia OR 3.6 (IC95% 1.9–6.8), and indications for CS other than dystocia (foetal distress, placenta praevia, scarred uterus) OR 0.14 (IC95% 0.02–1.03) (Table 6).

Table 6

Univariate and multiple logistic regression of the association of risk factors for neonatal mortality.

	OR (IC 95%)	p-value	aOR (IC 95%)	p-value
Intervention
No	1	0.14	1	0.21
Yes	0.58 (0.28–1.19)		0.69 (0.28–1.33)
Woman’sage in years	1.03 (0.98–1.09)	0.20
Marital status
Married	1	0.69
Single	0.8 (0.32–2.13)
Woman’slevel of education
None	1.7 (0.44–6.6)	0.24
Primary	0.24 (0.03–2.4)
Secondary	1.7 (0.48–5.8)
Higher	1
Other	2.4 (0.63–9.4)
Woman’s occupation
Housewife	1	0.52
Job	0.76 (0.31–1.9)
Other	1.4 (0.62–3.4)
Primary residence
Urban area	1	0.46
Rural area	1.3 (0.62–2.8)
Parity
0	1	0.11
1–3	2.8 (1.0–7.3)
≥ 4	2.7 (0.93–7.7)
Number of previous caesareans
0	1	0.57
1	0.73 (0.30–1.80)
≥ 2	1.22 (0.57–2.62)
Hospital in the health zone of the woman’s village of origin
Yes	1	0.33
No	1.4 (0.72–2.64)
Type of admission
Normal prior to onset of labour
Emergency during labour
Mode of admission
Referral prior to onset of labour	1	0.47
Referral during labour	1.1 (0.42–2.98)
Personal decision prior to onset of labour	0.34 (0.07–1.69)
Personal decision during labour	1.03 (0.40–2.65)
Fundal height in centimetres before caesarean
	0.96 (0.87–1.05)	0.38
Presentation of the foetus
Cephalic	1	0.03	1	0.007
Breech	1.2 (0.36–4.0)		0.75 (0.17–3.2)
Other	4.4 (1.4–13.3)		6.3 (2.0–20)
Onset of labour
Spontaneous	1	0.06
Induced	2.5 (1.2–5.3)
Caesarean before labour	1.5 (0.50–4.3)
Type of primary anaesthesia
Loco-regional	1	< 0.0001	1	0.001
General	3.6 (1.9–6.8)		3.1 (1.6–6.2)
Pre-operative indication for Caesarean 1
Pelvic anomaly
No	1	0.05
Yes	0.14 (0.02–1.03)
Post-operative indication for Caesarean 1
Pelvic anomaly
No	1	0.05
Yes	0.14 (0.02–1.00)
Scarred uterus
No	1	0.54
Yes	0.79 (0.37–1.68)

Our study showed more post-operative complications among single women OR 1.8 (IC95% 1.3–2.7), multigravidas OR 2.1 and 1.9, women who had a history of at least two prior CSs OR 3.3 (IC95% 2.3–4.6), or those who had a job (OR 4.8) or a low level of education (OR 3.5, 4), living in a rural area or far from the hospital in the health zone of their village of origin OR 7 (IC95% 4.9–10). Non-cephalic presentation of the fetus (OR 0.86, 2.6), a CS prior to onset of labour OR 3 (IC95% 1.9–4.8) and indications such as dystocia are associated with more post-operative complications OR 0.48 (IC95% 0.28–0.67) (Table 7).

Table 7

Univariate logistic regression of the association of risk factors for post-operative complications.

	Complications n(%)	OR (IC 95%)	p-value
Woman’sage in years		0.99 (0.97–1.02)	0.56
Marital status
Married	271 (31.8)	1	0.001
Single	60 (46.2)	1.8 (1.3–2.7)
Woman’slevel of education
None	95 (53.4)	3.5 (2.1–6.0)	< 0.0001
Primary	85 (56.3)	4.0 (2.3–6.8)
Secondary	122 (30.1)	1.3 (0.81–2.16)
Higher	26 (24.5)	1
Other	5 (3.9)	0.12 (0.05–0.33)
Woman’s occupation
Housewife	185 (26.7)	1	< 0.0001
Job	116 (63.4)	4.8 (3.4–6.7)
Other	38 (32.5)	1.3 (0.87–2.0)
Primary residence
Urban area	213 (26.5)	1	< 0.0001
Rural area	129 (71.7)	7.0 (4.9–10)
Parity
0	61 (23.1)	1	0.0001
1–3	193 (39.1)	2.1 (1.5–3.0)
≥ 4	88 (35.9)	1.9 (1.3–2.7)
Number of previous caesareans
0	96 (23.9)	1	< 0.0001
1	82 (35.7)	1.8 (1.2–2.5)
≥ 2	12 ((50.6)	3.3 (2.3–4.6)
Hospital in the health zone of the woman’s village of origin
Yes	160 (29.1)	1	0.001
No	156 (39.1)	1.6 (1.2–2.1)
Type of admission
Normal prior to onset of labour
Emergency during labour
Fundal height in centimetres before caesarean
		1.04 (1.00–1.08)	0.05
Presentation of the foetus
Cephalic	300 (33.6)	1	0.03
Breech	21 (30.4)	0.86 (0.51–1.47)
Other	17 (56.7)	2.6 (1.2–5.4)
Onset of labour
Spontaneous	274 (35.5)	1	< 0.0001
Induced	11 (8.5)	0.17 (0.09–0.32)
Caesarean before labour	51 (62.2)	3.0 (1.9–4.8)
Type of primary anaesthesia
Loco-regional	241 (36.1)	1	0.04
General	98 (29.6)	0.74 (0.56–0.99)
Pre-operative indication for Caesarean 1
Pelvic anomaly
No	305 (35.8)	1	< 0.0001
Yes	28 (19.4)	0.43 (0.28–0.67)

Discussion

Caesarean frequency

Our study shows an average CS proportion of 17%, which is in line with the average rate of 10 to 15% recommended by the WHO [16]. These WHO recommendations are valid particularly for scheduled caesarean sections, for which the proportion should be very low except in centers for high-risk pregnancies. The CS proportion seen in our study is higher than that seen among the general population in the Democratic Republic of Congo (DRC) [9]. One study analysed the proportion of CS in SSA and showed an average CS rate of 19% [17], which is in line with the overall estimate described in the literature [18]. Another study on the analysis of CS practices in SSA described a CS ranging from 2% to 52% [19]. This study showed that the rate varies depending on the population studied and on access to healthcare [19]. The proportion of CS is higher in both groups at the North Kivu provincial hospital, which is a skills development center for health staff in the province and as such receives more referrals from outlying facilities. The PADISS project (to support the health system’s integrated development), developed by ULB (Universitélibre de Bruxelles) Cooperation and Erasme Cooperation alongside the local authorities, is firmly established in the North Kivu health system and is working simultaneously on different key elements that make it possible to offer the population higher quality, consistent, effective healthcare. Its objective is to improve the quality and accessibility of healthcare in the province of North Kivu and to ensure its stability by gradually putting in place, in line with the contractual subsidy scheme which is being implemented in the province, a system for the accreditation of health facilities and staff as well as the necessary elements for their proper operation. The presence of this project explains the higher CS frequency at North Kivu provincial hospital. Although a CS is an effective technique for preventing maternal and perinatal mortality when used appropriately, it is not risk free and is associated with short- and long-term complications [20]. These rates have risen in developed and developing countries alike, sometimes reaching very high rates as, for example, in Brazil and the United States [21].

Indications for caesarean

For both groups, approximately 62% of the caesarean sections had been performed as an emergency during labour. The emergency CS rate in both groups is as high as the rates given in the literature for the DRC and other regions in developing countries, which report emergency CS rates ranging from 58% to 98%. Some reasons for these high CS rates include the absence of quality antenatal care which can prophylactically detect and refer high-risk pregnancies toward specialist facilities, the dramatic rise in makeshift and uncertified maternity units, the low level of qualification of health staff working in these maternity units, lack of awareness of the counter-indications for vaginal birth followed by delayed transfer to specialist facilities, poor distribution of health centers and difficult access to referral facilities, as well as poverty and illiteracy among these populations [10, 22]. These are common factors and characteristics, in varying degrees, of developing countries. Although the CS had been performed more as an emergency in both studies, the majority of patients had been referred before and during labour to the better equipped hospital, labour was more often spontaneous, there were fewer cases of induced labour and the CS was performed more frequently prior to labour in the study after the staff training. The main indications for CS in both studies were dystocia, foetal distress and a scarred uterus.

Dystocia (difficult and protracted labour) was the primary indication for CS in both groups. Dystocia is mainly caused by insufficient uterine contractions, sometimes due to cephalopelvic disproportion, lack of progress in foetal descent due to a tumour; however, it is sometimes difficult to make this diagnosis prior to labour [19]. Certain authors wondered whether dystocia was being over-diagnosed nowadays, in order to justify more frequent use of CS [11]. Our study shows fewer indications of dystocia after training than before (p = 0.005).

A scarred uterus was one of the primary indications for caesarean sections. The “once a caesarean always a caesarean” policy is widely applied in SSA, mainly from fear of uterine rupture during labour. This policy helps reduce both the uterine rupture rate and the emergency surgery responsible for the increase in maternal and perinatal mortality and morbidity [19]. These repeat caesareans do not, however, result in the medical benefits expected. In fact, a vaginal delivery after a caesarean section has a low risk both for the mother and for the child [23]. The risk of uterine rupture increases with the number of previous CS and our study shows that a CS was most often performed on a multi-scarred uterus after the training than before (p < 0.0001).

Foetal distress was one of the main indications for CS in our study. The accuracy of this diagnosis is sometimes doubtful. Foetal monitoring is not yet used continuously in many of these medical facilities, and health staff still need to be trained in its interpretation. One study on foetal monitoring was unable to show an improvement in the infants’ well-being parameters in relation to the use of a Pinard stethoscope [24]. However, this study showed an increase in the use of caesarean section when monitoring was used, because it is difficult to make the distinction between foetal stress and true distress, as shown by these authors [25]. Monitoring gives a high false positive rate for foetal distress: as such, it is advisable to use ST analysis (STAN) or scalp pH, which is non-existent in these medical facilities. It would be worthwhile setting up foetal monitoring and ST analysis or scalp pH in these different facilities in order to reduce this false positive rate along with the CS rate for foetal distress. In the DRC, one study determined foetal distress as a pre-operative indication for CS in 23% of cases in urban settings in university clinics in Kinshasa, whereas in the same period, the rates reported in semi-urban settings (Mbuji-Mayi) and rural settings in the same country were 1.5% and 0% respectively [26]. This rate of 23% in urban settings is higher than that described in our study. One explanation for this is that foetal distress is correctly diagnosed in university hospital settings where more labour monitoring equipment is available. Our study showed fewer diagnoses of foetal distress after training than before, but this difference was not statistically significant (p = 0.11).

Other indications such as haemorrhagic placenta praevia, uterine pre-rupture and rupture, and breech, brow and transverse presentation explain the high rate of emergency CS in our study.

Maternal risks

Intraoperative complications were approximately 2.5% in both groups; however, post-operative complications were higher in group 2 (p < 0.0001), explained by the fact that the patient’s file was more complete (p < 0.0001), and more incisions were transverse (p < 0.0001) in group 2. The staff who performed the CS were more qualified in group 2 (p = 0.015). According to the Cochrane systematic review, the Joel-Cohen incision has advantages over the sub umbilical midline incision, resulting in fewer cases of fever, pain, need for analgesics, blood loss, and a shorter procedure and hospitalization duration. However, these studies do not provide information relating to mortality and severe or long-term morbidity [27]. Maternal mortality was higher in group 2 (p = 0.046) due to the fact that the patients’ files were more complete, deaths were properly recorded, and the training made it possible to select at-risk cases giving a high maternal mortality, but which remains low in relation to several regions in SSA. This decrease in mortality may be explained by the fact that patients were not monitored up to 42 days post-partum, because the average stay in hospital was five days. While CS is safer in developed countries, it still entails the risks of many major abdominal procedures in the DRC. Maternal mortality is estimated to be approximately 2 to 11 times higher after a CS than after a vaginal delivery [28]. There were fewer blood transfusions performed after the training (p = 0.04), explained by the fact that several risk factors for anaemia had been identified during the antenatal visits, of which there were more after the training.

Perinatal risks

Our study describes fewer neonatal deaths after the training than before, but this difference is not statistically significant (p = 0.14). This neonatal mortality was primarily associated with the use of general anaesthesia. One retrospective study gave a newborn infant death rate of 9% after CS or an APGAR score lower than 7 at five minutes after birth [29]. This rate was comparable with the results described in Africa where a WHO study showed an average neonatal mortality rate of 12.9% after a CS [6]. Our findings on mortality rates were lower than those described by other studies [6, 30]. The use of general anaesthesia shows that the majority of CS had been performed as an emergency and were accompanied by more maternal and perinatal risks as shown by these authors [31]. Neonatal mortality was higher among multiparous patients as described in other studies conducted in Rwanda and Nigeria [32]. One possible explanation for this is that women who have more children are often poor and less educated [32]. Poverty and a low level of education have been associated with poor neonatal outcomes in SSA [30]. Our study shows more cases of low birth weight after training than before (p < 0.002). The association of risk factors for low birth weight is related to health staff training, primary residence, mode of admission, fundal height before the CS, non-cephalic presentation of the foetus, and the use of general anaesthesia. However, we recommend continuing efforts to raise awareness among pregnant women as to the value of antenatal visits with a view to decreasing the maternal and perinatal risks shown in our results and those of other studies [33].

There are several limitations to take into account in this comparative study. Given the cross-cutting nature of the two studies, and certain shortcomings in medical practice, several variables were lacking data in the retrospective study, such as size, weight for calculating the body mass index, gestational age at the time of the CS, and a partograph in the medical file in order to assess the diagnosis of dystocia or dyskinesia. This study was conducted in hospital facilities in Goma, and does not therefore reflect the situation in rural areas of North Kivu and the rest of the DRC.

Conclusion

Caesarean section should be a factor in reducing foeto-maternal morbidity and mortality if the transfer conditions, the working conditions at referral center level, and staff training are improved. Our study showed more post-operative complications, more maternal deaths, more cases of scarred uterus, more low-birth weight infants, fewer indications of foetal distress and dystocia, and fewer neonatal deaths in group 2. The PADISS project will help to improve the maternal and perinatal risks seen in this comparative study. It may be necessary to improve the conditions for transferring patients to referral hospitals, the training of health staff involved in antenatal visits in order to ensure timely detection and referral of high-risk pregnancies to referral hospitals which must have adequate equipment for providing quality emergency caesarean sections and neonatal care in order to reduce the perinatal risks associated with CS. A wide-scale prospective study may be necessary to assess the impact of the training on improving the quality of CS procedures in North Kivu and the Democratic Republic of Congo.

(XLSX)

Click here for additional data file.

(XLS)

Click here for additional data file.

10 Aug 2021

PONE-D-20-41094

EVOLUTION IN CAESAREAN SECTION PRATICES IN NORTH-KIVU; IMPACT OF CAREGIVER TRAINING

PLOS ONE

Dear Dr. dikete ekanga,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

The reviewer has requested some additions and revisions, in addition to the items raised by the reviewer, please address the following points before more consideration:

It appears the authors must use multiple regression (only one dependent variable in each model) instead of multivariate (more than two dependent variables).

Please report regression prerequisite in method section and its handling methods.

Provide B: Unstandardized coefficients, S.E.: Standard error and Beta: Standardized regression coefficients for variable and model Goodness of Fit in regression table.

Please present abbreviation (OR, AOR, ….) in their full format first time.

It appears in regression analysis reported in tables’ 5-7 only women with selected condition (only women’s with low birth weight, only women’s with neonatal mortality and only women’s with postoperative complications) considered as cases and were included in modeling and other cases were excluded. In regression analysis your dependent variable is women’s condition in relation to selected variables and group (Intervention – and Intervention -+) is your independent variable. And other factors were confounding factors. Statistical analysis must be reviewed and corrected before more consideration.

In intervention section you declared “Following these findings, specific training was given to the local health staff.”, but we do not have any findings before this section.

Provide your ethic statement in method section and ethic committee approval form as appendix.

In addition, the reviewers request improvements to the clarity of the written language.

Please submit your revised manuscript by Sep 24 2021 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

If applicable, we recommend that you deposit your laboratory protocols in protocols.io to enhance the reproducibility of your results. Protocols.io assigns your protocol its own identifier (DOI) so that it can be cited independently in the future. For instructions see:  http://journals.plos.org/plosone/s/submission-guidelines#loc-laboratory-protocols . Additionally, PLOS ONE offers an option for publishing peer-reviewed Lab Protocol articles, which describe protocols hosted on protocols.io. Read more information on sharing protocols at  https://plos.org/protocols?utm_medium=editorial-email&utm_source=authorletters&utm_campaign=protocols .

We look forward to receiving your revised manuscript.

Kind regards,

Kamal Gholipour, PhD

Academic Editor

PLOS ONE

Journal Requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf.

2. Please provide additional details regarding participant consent for your prospective study. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

3. In your ethics statement in the manuscript and in the online submission form, please ensure that you have discussed whether all data/samples were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent for the retrospective study. If patients provided informed written consent to have data/samples from their medical records used in research, please include this information.

4. In the ethics statement in the manuscript and in the online submission form, please provide additional information about the patient records/samples used in your retrospective study, including the date range (month and year) during which patients' medical records/samples were accessed.

5. Thank you for stating the following financial disclosure:

"This research work has not been funded by any organization. It is a research work in collaboration with the Free University of Brussels and the Erasmus Brussels Academic Hospital"

At this time, please address the following queries:

a) Please clarify the sources of funding (financial or material support) for your study. List the grants or organizations that supported your study, including funding received from your institution.

b) State what role the funders took in the study. If the funders had no role in your study, please state: “The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.”

c) If any authors received a salary from any of your funders, please state which authors and which funders.

d) If you did not receive any funding for this study, please state: “The authors received no specific funding for this work.”

Please include your amended statements within your cover letter; we will change the online submission form on your behalf.

6. We note that you have stated that you will provide repository information for your data at acceptance. Should your manuscript be accepted for publication, we will hold it until you provide the relevant accession numbers or DOIs necessary to access your data. If you wish to make changes to your Data Availability statement, please describe these changes in your cover letter and we will update your Data Availability statement to reflect the information you provide.

7. PLOS requires an ORCID iD for the corresponding author in Editorial Manager on papers submitted after December 6th, 2016. Please ensure that you have an ORCID iD and that it is validated in Editorial Manager. To do this, go to ‘Update my Information’ (in the upper left-hand corner of the main menu), and click on the Fetch/Validate link next to the ORCID field. This will take you to the ORCID site and allow you to create a new iD or authenticate a pre-existing iD in Editorial Manager. Please see the following video for instructions on linking an ORCID iD to your Editorial Manager account: https://www.youtube.com/watch?v=_xcclfuvtxQ.

8. Please include your full ethics statement in the ‘Methods’ section of your manuscript file. In your statement, please include the full name of the IRB or ethics committee who approved or waived your study, as well as whether or not you obtained informed written or verbal consent. If consent was waived for your study, please include this information in your statement as well.

9. We note you have included a table to which you do not refer in the text of your manuscript. Please ensure that you refer to Table 4 in your text; if accepted, production will need this reference to link the reader to the Table.

10. Please include your tables as part of your main manuscript and remove the individual files. Please note that supplementary tables (should remain/ be uploaded) as separate "supporting information" files.

[Note: HTML markup is below. Please do not edit.]

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

Reviewer #3: Partly

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

Reviewer #3: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: The objective of this study was to determine the impact of health staff training in a region of the DRC and which focused on the quality of C-section procedures by comparing outcomes determined at 2 sequential time points.

Multivariate logistic regression is used to determine which characteristics were associated with maternal and perinatal mortality and morbidity.

It is unlikely that dystocia or true fetal distress rates would be directly related to training, rather changes may be a reflection on how these diagnoses were defined and reported. A reduction in neonatal deaths is a “hard” indicator and maybe associated with the quality of training provided. The increase in scarred uteri may simply reflect a relative increase in the total number of prior cesarean sections. While training is relevant to ensure safe surgery practices for this group of women, in order to maximize study findings, it may be best to focus on outcomes among nulliparous women. Low birth weight is associated with a number of direct and indirect causes including access to adequate nutrition and the presence of micronutrient deficiencies, especially that of iron and folic acid.

Validated training and implementation of training procedures will likely not be a direct cause of untoward clinical outcomes. However, fetal distress is often cited as the reason for surgical intervention.

Cesarean sections performed in sub-Saharan African countries, while often indicated, are associated with higher rates of poor outcomes than those reported from other regions. The 3 Delays, including time to reach a facility as well as training and facility infrastructure must be addressed in future studies.

A few questions:

Was there a reduction in fistulas or reports of incontinence?

How often was the WHO partogram used?

Was there a difference in outcome between non-emergent c-section patients as compared to the two thirds of women who were considered emergencies?

During the second phase of this study, was more electronic monitoring equipment available?

Was there a report by the ERASMUS training team on their observations relative to the overall quality of care and challenges that need to be addressed?

There has been a paucity of papers related to cesarean section rates and outcomes in the DRC. While it is difficult to draw meaningful conclusions from the data presented, the paper is still an important contribution in demonstrating the difficulties of addressing composite training needs in the face of limited resources and a challenging topography.

Reviewer #2: Unvariate and multivariate logistic regression was performed to determine which characteristics are associated with maternal and perinatal morbidity and mortality.These research methods are scientific and reasonable.

However, there are still some problems in this paper:

Baseline population was recruited from referral hospitals in the city of Goma from the period 01/11/2013 to 01/01/2016 (group 1).The second group was recruited from the same hospitals in Goma for the period from June 2019 to January 2020 (group 2). The time period of the two groups of people is not consistent, which may have an impact on the comparison results. It is suggested to explain this in the discussion or in the deficiencies of this paper.

The writing of the article should be standardized. For example, all tables should be three-line tables.The article lacks key words.

Reviewer #3: 1. In the section of result，authors concluded that “Our study shows more cases of low birth weight, more post-operative complications, more maternal deaths, lower perinatal mortality… in group 2(after intervention) than in group 1(before intervention).”(as shown in Table 4). However, multivariate logistic regression did not support the conclusion. As shown in Table 5, intervention had no statistically significant impact on low birth weight (OR=1.9, P=0.13). As shown in Table 6, intervention had no statistically significant impact on neonatal mortality (OR=0.69, P=0.21). Given the fact that there are significant differences in socio-demographic characteristics, medical data and obstetric characteristics between the two groups, multivariate logistic regression result is more reliable. Also, the result of multivariate logistic regression should be added in the abstract.

2. Is it reasonable to choose low birth weight, maternal deaths, and perinatal mortality as the evaluable indicator? The objective of the study is to assess the impact of health staff training on the quality of CS procedures. Firstly, low birth weight cannot reflect the quality of CS procedures very well; Secondly, the incidence rate of maternal deaths, and perinatal mortality is very low, it is hard to measure a significant difference (unless the sample size is very large). Maybe the indicator such as operative time, blood loss, APGAR, duration of stay and post-operative complications are more suitable.

3. APGAR and duration of stay were compared between the two groups in the study, but the result did not described in the abstract. Although there are no statistical significance in APGAR between the two groups by Chi² Pearson test, a multivariate logistic regression should be added to assess the impact of intervention on APGAR.

4. In table 7, the variable “intervention” should be added. Also, multivariate logistic regression result should be added to assess the impact of intervention on post-operative complications.

5. In the study, statistical analysis is performed appropriately, but the interpretation of the statistical results requires improvement. In the abstract, “Our study shows a decrease in neonatal deaths, dystocia and foetal distress, but an increase in post-operative complications, maternal deaths and cases of scarred uterus and low birth weight.” Among them, dystocia, foetal distress and scarred uterus is the obstetric characteristics of maternal, which can hardly be influenced by health staff training and cannot reflect the quality of CS procedures very well.

6. Some data should be checked. For example, the data of post-operative complications in table 4 should be checked.

7. In the abstract “In the population studied prospectively, after the implementation of health staff training, there were fewer cases of dystocia, foetal distress and neonatal death, but more cases of scarred uterus, post-operative complications and low birth weight.” The word “cases” is not used properly. Maybe “incidence rate” is more suitable.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

21 Sep 2021

After thorough analysis of all the comments made to this document, we sincerely thank the 3 reviewers for their time and also the way in which the article was corrected. We can only encourage other colleagues and ourselves to submit research to Plos One.

Submitted filename: Response to reviewers.docx

Click here for additional data file.

8 Nov 2021

30 Nov 2021

Dear reviewers, I am very pleased to have had you for the evaluation of this study conducted in this region of the Democratic Republic of the Congo very difficult because of the war for several years. I will certainly take into account all your recommendations in our next study and I would like to take this opportunity to thank you for your precious time in helping us improve this work.I will be sure to recommend my other colleagues and researchers to your journal

Submitted filename: Response to Reviewer Comments October 26Nov-WHZ.docx

Click here for additional data file.

13 Dec 2021

3 Feb 2022

Thank you for all your comments that helped me improve this article

8 Feb 2022

EVOLUTION IN CAESAREAN SECTION PRACTICES IN NORTH-KIVU; IMPACT OF CAREGIVER TRAINING

PONE-D-20-41094R3

Dear Dr. dikete ekanga,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Kamal Gholipour, PhD

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

17 May 2022

PONE-D-20-41094R3

EVOLUTION IN CAESAREAN SECTION PRACTICES IN NORTH KIVU: IMPACT OF CAREGIVER TRAINING

Dear Dr. Dikete Ekanga:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Kamal Gholipour

Academic Editor

PLOS ONE