Abstract

Background: Obstetric delivery is the most frequent cause of hospital admission and the length of stay in hospital after birth varies from one country to another and from one maternity unit to another, depending on economic factors, attitudes to childbirth and traditions in obstetric care. Objective: The aim of this study was to analyze the trends and determinants of hospital discharge following uncomplicated caesarean section in South-Eastern Nigeria tertiary hospitals. Methodology: It is a cross-sectional questionnaire based study. The study population comprises Gynaecologists and Obstetricians practicing in tertiary hospitals in south eastern Nigeria. The study was carried out among obstetricians-Gynaecologist at the Federal Teaching Hospital Abakaliki (FETHA) and those who attended the Eastern sector zonal meeting of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) held on 9^TH September 2017 in Enugu coal-city, Enugu State, Nigeria. Results: The study included 286 participants. The study showed that few (16.7%) of the patients had early discharge and late hospital discharge accounted for 83.3%. The determinants of early hospital discharge were cost of treatment (11.8%), obstetricians personal preferences (10.8%), lack of bed space (4.9%) and patient choice (4.9%). Hospital policy (36.3%) and fear of readmission for maternal or neonatal complications (59.8%) are major reasons for late hospital discharge following uncomplicated caesarean section.

1. Introduction

Obstetric delivery is the most frequent cause of hospital admission and the length of stay in hospital after birth varies from one country to another and from one maternity unit to another, depending on economic factors, attitudes to childbirth and traditions in obstetric care. ^{1, 2, 3, 4, 5}

It has become common practice to discharge women from hospital early after caesarean section, to satisfy their wishes or to reduce workload. ^{6, 7} During the last 60 years there has been a worldwide tendency to reduce the length of time women stay in the hospital after giving birth. ⁸ The issue of the appropriate length of stay after delivery is complex and hotly debated. ^{9, 10, 11, 12} In 1992, the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommend a 2-day stay after a vaginal delivery and a 4-day stay after a cesarean section if there have been no complications. ⁴ Studies have also shown that early discharge of healthy mothers is beneficial to the mothers in terms of their physical and emotional health, as well as to the facilities in terms of economic considerations. ^{13, 14, 15, 16, 17, 18}

The aim of this study was to analyze the trends and determinants of hospital discharge following uncomplicated caesarean section in South-Eastern Nigeria tertiary hospitals.

2. Materials and Methods

The study was carried out among Obstetricians-Gynaecologist at the Federal Teaching Hospital Abakaliki (FETHA) and those who attended the Eastern sector zonal meeting of the Society of Gynaecology and Obstetrics of Nigeria (SOGON) held on 9^TH September 2017 in Enugu coal-city, Enugu State, Nigeria. The Society of Gynaecology and Obstetrics of Nigeria is an umbrella professional organization of Gynaecologists and Obstetricians in Nigeria. It has a vision that Nigerian women achieve the highest possible standards of physical, mental, reproductive and sexual health and wellbeing throughout their lives.

Federal Teaching Hospital Abakaliki (FETHA) is located in Ebonyi State; one of the five states in the South-East Geopolitical zone of Nigeria. It was created in 1996 from the largely rural areas of the pre-existing Enugu and Abia states. It has an estimated population of 2.1 million people (2006 census) and occupies a land mass of 5932km², sharing boundaries in the West with Enugu state, Cross-river in the South and Benue state in the North. There are 13 general hospitals, one in each LGA and the Federal Teaching Hospital Abakaliki is located within the centre of the state capital. It receives referrals from the general hospitals, mission hospitals and primary health centres as well as privately owned hospitals and clinics. It also receives referral from neighboring states of Benue, Enugu, Cross-River and Abia.

It is a cross-sectional study. The study population comprises Gynaecologists and Obstetricians practicing in tertiary hospitals in south eastern Nigeria.

A structured and pre-tested questionnaire was prepared in English language. Data was collected by the researchers. The questionnaire has two parts. The first part included socio-demographic variables. The second part assessed patterns/reasons for choice of postoperative hospital discharge. The questionnaires were given to the participants who answered and returned them to the researchers.

Data quality was controlled through the provision of training to the data collectors and supervisors about the overall data collection procedures. The collected data was checked for completeness, consistency, accuracy and clarity by the supervisor and the principal investigator.

All returned questionnaires were checked manually for the completeness and consistency of responses. The collected data was coded and entered and analyzed using Epi Info version 7.0 (CDC, USA). For the descriptive analysis, continuous variables were summarized using means, medians, and standard deviations (SDs), while categorical variables were summarized using proportions.

Before commencement of the study, ethical approval was sought for and obtained from the Research and Ethical Committee of the Federal Teaching Hospital, Abakaliki. Written informed consent was obtained from each study participant to confirm willingness to participate after explaining the objective of the study. Respondents’ names and personal identifiers were not included in the written questionnaires.

3. Results

The study included 286 participants. The mean age of the study participants was 37.9 ± 7.6. Majority (80.4%) of the study participants were males. Registrars accounted for 52% of participants. Of those who participated in the study, 92.2% practice in urban areas (Table 1).

The study showed that few (16.7%) of the patients had early discharge and late hospital discharge accounted for 83.3% (Table 2). The determinants of early hospital discharge were cost of treatment (11.8%), obstetricians personal preferences (10.8%), lack of bed space (4.9%) and patient choice (4.9%) (Table 2). Hospital policy (36.3%) and fear of readmission for maternal or neonatal complications (59.8%) are major reasons for late hospital discharge following uncomplicated caesarean section (Table 2).

The duration of hospital admission from this study was determined by the indication for caesarean section (82.4%), postoperative haemoglobin level (69.6%), clinical state of the mother (67.6%), tolerance of oral intake (47.1%) and type of skin closure (31.4%). (Table 2).

Reduced hospital cost (87.3%), lower risk of nosocomial infection (75.5%), faster maternal recovery (39.2%) and higher maternal satisfaction (54.9%) are some of the benefits of early discharge cited by the study participants (Table 2).

Postoperative complications following early discharge were uncommon. Majority (61.8%) of participants cited no complications among the patients that had early hospital discharge (Table 2). The commonest complication encountered among women that had early discharge was wound breakdown (14.7%). According to the study, the ways to enhance early hospital discharge following uncomplicated caesarean section include proper patient counseling (55.9%), proper patient selection (71.6%), early ambulation (80.4%), early initiation of oral feeding (53.9%), early removal of urethral catheter (55.9%), subcuticular skin closure (41.2%) and reduced institutional barrier to early discharge (40.2%) (Table 2).

4. Discussions

This study addressed the issue of variation in obstetric care length of stay and identifying the important variables that affect maternity length of stay following uncomplicated caesarean section in South- eastern Nigeria.

The main objection to early discharge following uncomplicated caesarean section is the contention that the safety of the mother is jeopardized. The present study produced no evidence to support this opinion. Majority (61.8%) of patients had no complications following early hospital discharge. This finding is similar to findings of studies done in California and India. ^{1, 3} Therefore it is safe to discharge women who had uncomplicated caesarean section early especially in our low resource setting where most women are of low socioeconomic status.

There was a substantial variation in length of hospital stay in this study. The variation was attributed to patient clinical risk factors and presence of complications. This finding is similar to findings of a study done in Sydney. ⁵ This showed that the clinical status of patient is a key determinant of length of hospital stay following caesarean section.

Postoperative complications following early discharge were uncommon. The commonest complication encountered among women that had early discharge was wound breakdown (14.7%). This finding correlates with the finding of a study in India. ¹ Therefore adequate effort should be made to prevent this complication by observing strict asepsis during surgery, antibiotic use and proper wound care in the postoperative period.

Discharging women without complications in early post-operative period is an advantageous means of reducing the cost of health care system and expenditure of the family. Most women in developing countries like Nigeria belong to low socio-economic status and are the bread winners of the family. If a patient is admitted for a prolonged period, this will create debt to the family which in turn causes economic burden and psychological stress. This will reflect on the post-natal nutrition to the mother and baby. Hence early hospital discharge following uncomplicated caesarean section should be enhanced by proper patient counseling, proper patient selection, early ambulation, early initiation of oral feeding, early removal of urethral catheter, subcuticular skin closure and reduced institutional barrier to early discharge.

References