Classifying caesarean section to understand rising rates among Palestinian refugees: results from 290,047 electronic medical records across five settings

Abstract

Background Rising caesarean-section rates worldwide are driven by non-medically indicated caesarean-sections. A systematic review concluded that the ten-group classification system (Robson) is the most appropriate for assessing drivers of caesarean deliveries. Evidence on the drivers of caesarean-section rates from conflict-affected settings is scarce. This study examines caesareans-section rates among Palestinian refugees by seven-group classification, compares to WHO guidelines, and to rates in the host settings, and estimates the costs of high rates. Methods Electronic medical records of 290,047 Palestinian refugee women using UNRWA’s (United Nations Relief and Works Agency for Palestine Refugees in the Near East) antenatal service from 2017–2020 in five settings (Jordan, Lebanon, Syria, West Bank, Gaza) were used. We modified Robson criteria to compare rates within each group with WHO guidelines. The host setting data were extracted from publicly available reports. Data on costs came from UNRWA’s accounts. Findings Palestinian refugees in Gaza had the lowest caesarean-section rates (22%), followed by those residing in Jordan (28%), West Bank (30%), Lebanon (50%) and Syria (64%). The seven groups caesarean section classification showed women with previous caesarean-sections contributed the most to overall rates. Caesarean-section rates were substantially higher than the WHO guidelines, and excess caesarean-sections (2017–2020) were modelled to cost up to 6.8 million USD. We documented a steady increase in caesarean-section rates in all five settings for refugee and host communities; refugee rates paralleled or were below those in their host country. Interpretation Caesarean-section rates exceed recommended guidance within most groups. The high rates in the nulliparous groups will drive future increases as they become multiparous women with a previous caesarean-section and in turn, face high caesarean rates. Our analysis helps suggest targeted and tailored strategies to reduce caesarean-section rates in priority groups (among low-risk women) organized by those aimed at national governments, and UNRWA, and those aimed at health-care providers.

Quality of maternal and newborn health care at private hospitals in Iraq: a cross-sectional study

“…In this context, reducing the practice of non-medically indicated cesareans has proven challenging, but there is substantial evidence that introduction of action-oriented monitoring strategies and systems to evaluate trends in cesarean rates, care practices and outcomes have identified opportunities to improve quality of care for mothers and newborns [ 25 , 26 ]. Other countries in the region have documented an increase in neonatal intensive care unit admissions associated with an increase in cesarean rates, including scheduling of elective procedures at late preterm and early term gestation, and instituted practices to reduce the frequency of pre-term births [ 27 ].…”

Establishment of a birth-to-education cohort of 1 million Palestinian refugees using electronic medical records and electronic education records

“…The setting also reflects the timing of the introduction of E-health and the overall quality of record keeping and data entry which can in turn affect linkage. There are several indications from previous work [ 23 ] that records from Syria have the poorest recording of birth dates, and that data quality (assessed via digit preference and heaping) are weakest in Syria and Jordan. The conflict situation in Syria has almost certainly impacted the accuracy of the data collected and the linkage process.…”

“…Migration might prevent the use of children’s health services. No studies of numbers of Palestinian-refugee specific migration were found in the literature, but news reports document that the adverse impacts of the conflict in Syria and the economic collapse in Lebanon on Palestinian refugees, have led to drownings during attempted illegal migrations [ 22 , 23 ].…”