SAAD COLLEGE OF NURSING AND ALLIED HEALTH SC.docx

SAAD COLLEGE OF NURSING AND ALLIED HEALTH
SCINCE - UNIVERSITY OF ULESTER
ACDAMIC YEAR 2018-19
Semester one
Assignment Title: Nutrition Knowledge among Young Pregnant
Women in Middle East.
Student name: Alreem Ali Alaliwat
ID number: SNC 146046 UU ID: B00697863
Cohort: 16 (Year 4 semester 2)
Course Title: B.Sc (Hons) in Nursing Studies
Module Title: Developing a research proposal
Module Code: NUS 585 CRN: 59064
Words Count: 6000
Date: 29/11/2018
Lecturer responsible for unit: Dr. Safia Belal

Table of Contents
Acknowledgement2
Abstract3
Chapter 15
Introduction5
1.Young Pregnant Women6
2.Nutrition Knowledge7
3.Education Need for Pregnant Words7
Significant Of the Study8
Aim of the Study9
Research Question9
Objective10
Research Question10
Chapter 211
Design11
Setting12
Sampling and Population13
Inclusion Criteria13
Exclusion Criteria13
Data Collection13
Ethical Considering14
Pilot Study15
Data Analysis16
Procedure of the Main Study17
Chapter 318
Time Scale18
Budget19
Expected Outcome20
References21
Appendix I Consent Form27
Appendix II Participant Leaflet27
Appendix III Questionnaire28
About Nutrition29

Acknowledgement:
First of all, I am thankful of Allah for helping me to complete
this research .
Through this paper, I'm a proud of working with all the
participant and I appreciate your efforts that were help and

support me especially my lovely husband and my sister
Dr.Ghada
Also I would like to give special thanks to Dr.Safiah Bilal ,
special thanx for here for the kindness, guidance,
encouragement, and suggestions du ring writing this study.
Alreem.
Nutrition Knowledge among Young Pregnant Women In Saudi
ArabiaAbstract:
Background: Nutrition plays a key role during pregnancy in the
sense that the nourishment that a pregnant woman gets
determines the nutrients that the developing fetus gets.
Nutrition knowledge in this case refers to information and skills
that an individual normally has pertaining food intake. In
respect to the research topic, this refers to information and
skills needed by pregnant women.
Aim: The aim of the study identify nutrition knowledge among
young pregnant women.
Sample: the sample population of these study is the young
pregnant women they take probability sample fore 100
participants.
Methodology: the researcher uses quantitative design for statics
and data analysis, as well random sample, it will be at Almanaa

Hospital.
Key words : Nutrition , knowledge , pregnancy
Nutrition Knowledge among Young Pregnant Women In Saudi
ArabiaChapter 1Introduction
The purpose of the study is to investigate and establish whether
pregnant young Saudi women have the needed nutritional
knowledge. Nutrition plays a key role during pregnancy in the
sense that the nourishment that a pregnant woman gets
determines the nutrients that the developing foetus gets. In
addition, women are the heads of the family and are directly
responsible for feeding the whole family, starting with the child
and the rest of the family. In terms of awareness and knowledge
of food and nutrition issues, the family health level will be
affected by malnutrition or healthy and healthy nutrition. A
questionnaire was designed for the purpose of collecting
research data and personal interview from a sample of research
subjects. They were women married to four villages randomly
selected from central region of Riyadh city as representative of
the human sample during the study period from January 2018 to
July 2018 (Al‐Meshari, 2014).
A set of statistical methods for analyzing the study data,
including frequencies and percentage percentages of the
computational and correlation coefficients of Spearman and
Pearson were used. (Pillitteri, 2010) During pregnancy, the
body of the woman prepares for the growth and development of

the foetus and the feeding process. The tissue in the body, such
as the uterus and placenta, also develops to supply blood, food
and oxygen to the foetus. Proper weight loss benefits the health
of women and the foetus, reduces risk and helps to give birth to
a healthy baby. Therefore, pregnant women at the beginning of
pregnancy to inform their doctor about her health and eating
habits such as plant nutrition, allergies to certain types of food
such , problems in digestion or diet, or women who suffer from
pressure or diabetes before pregnancy (El Mouzan, 2014).
The woman's body during pregnancy is subjected to several
changes, including physical and hormonal, and the method of
nutrition during pregnancy affect the health of women and the
foetus, so pregnant women follow a healthy and balanced diet to
maintain the health of mother and foetus throughout pregnancy
and avoid the risks that can be exposed, Pregnant women are the
main source of nutrition and growth of the foetus (Finer,
2017).Young Pregnant Women
The study will assess Is a female pregnancy under the age of 20
years. A female can have sexual contact after ovulation, which
can be prior to her first cycle but often occurs after the
menstrual cycle, which occurs during the age of 12 or 13 years.
Pregnant adolescents face the same as other women, but in
addition, females under the age of 15 suffer from physical
problems that prevent them from enjoying healthy pregnancy or
childbirth. From the age of 15 to 19 years, the risk is more than
biological, but also social and economic. Biological risks
include exposure to low birth weights, anemia, pre-eclampsia
and early delivery. If these risks are controlled, other risks
include not getting adequate parental care. (King, 2016).
In developing countries, teenage pregnancy is linked to social
issues, including low levels of education, poverty and other
things that represent a negative life for children and adolescent
mothers. (Madani, 2015). Also, when teenage pregnancy in
developing countries is out of wedlock, it stigmatizes many
cultures and societies. In addition, it is desired and welcomed
by the community and the family if it is within the framework

of marriage, although teenage pregnancy in these countries is
closely linked to malnutrition, lack of access to health care, and
poor health, which causes health problems.
The risk of unintended teenage pregnancy can be minimized by
promoting the concept of contraception. There are 3.7 million
women under the age of 18 giving birth every year in
developing countries. If this number is included in all the
world's pregnancy numbers, the proportion will be much higher.
(Mansour, 2014).
Pregnancy among girls younger than 18 years has dire
consequences that can not be fixed. It also violates the rights of
girls, with life-threatening consequences in terms of sexual
health and reproductive health, and costs very high amounts of
society, especially sustaining the cycle of poverty (Shawky,
2014). Health outcomes include not only the body's willingness
to conceive, but also the birth of adolescent lead to
complications, malnutrition and low-income family .
In low- and middle-income developing countries, the risk of
maternal death under the age of 15 is much higher than that of
women in their 20s. Teenage pregnancy also affects girls'
education. Many studies have addressed the social, economic,
medical and psychological impact of pregnancy and parenting in
adolescents. (Say, 2013).
Nutrition Knowledge :
Nutrition knowledge in this case refers to information and skills
that an individual normally has pertaining food intake. In
respect to the research topic, this refers to information and
skills needed by pregnant young Saudi women. The young
women will be asked to determine whether they know a few
types of foods that a pregnant woman needs to take. They will
for instance be asked to list the types of foods that any pregnant
woman needs to take. For those that will not be sure about the
specific type of food to eat, this will be taken to mean that they
lack the needed nutrition knowledge (Shawky, 2014).
Second, the young women will be asked to determine whether
they have in the past made personal effort to get information

about the appropriate diet for an expectant woman. The
significance of this inquiry is that it will be used to tell whether
these women take matters of nutrition seriously. If many women
for instance will report that they have not implemented what
they were taught in past functions about nutrition during
pregnancy, this will mean that the women did not understand
the information that was presented to them. The only people
that will be assumed to have understood the information are
those that went on to implement what they were told during past
events (Amin, 2015).
Third, the young women will be asked to determine whether
they are willing to make an effort to know what the needed type
of foods for a pregnant woman. In any case it will be
determined that the most pregnant young women are not willing
to take personal measure to learn about good nutrition during
pregnancy, this will imply that they have not understood the
logic behind good diet. On the contrary, if it will be determined
that most pregnant young woman are willing to begin educating
themselves about good education, this will be taken to mean
that the women have understood the underlying logic behind
good nutrition (Mahfouz, 2013). Education Need for
Pregnant
The young pregnant women need to be educated about the type
fruits and vegetables that they need to eat when pregnant. They
for instance need to be told that they need to eat such fruits as
oranges, mangoes and avocados. The significance of eating
oranges during pregnancy is that they help keep the pregnant
woman hydrated throughout the day. Mangoes on the other hand
contain vitamin c which helps increase the immune system of
pregnant women and the unborn fetus. The fetus need to have a
high immune system for the reason that most of the body parts
are so delicate and so if affected by an illness will lead to
serious cases (Alsulyman, 2015).
Second, pregnant women need to be educated about type fruits
and vegetables that they need to avoid when pregnant. Examples
of fruits that pregnant women need to avoid during pregnancy

include pineapple, grapes and watermelons. It is important to
educate the young pregnant on this since most of them assume
that all fruits are good for eating during pregnancy. Other than
certain fruits and vegetables not being idea for eating during the
pregnancy period, there are those that do not add important
nutrients that a fetus or even the expectant needs. What this
means is that eating them will be a waste of resources that will
have been used to buy important fruits (Musaiger, 2016).
Additionally,the young pregnant women need to be educated on
the compelling reasons as to why they really need the fruits and
vegetables. It will be inappropriate to tell the young pregnant
women that they need to feed on a certain type of diet without
giving those compelling reasons as to why they need this
particular diet. Failure to give the young pregnant women
compelling reasons will make them less willing to take personal
initiatives. If the young pregnant women for instance are told
that fruits contain vitamins that are vital for the development of
the muscles of their fetus, this reason will motivate them to eat
fruits (Al-Rethaiaa, 2014).
Significant Of the Study
Pregnancy is one of the most important stages in a woman's life.
She experiences many physical, psychological and emotional
fluctuations. She feels that she shares life with her child, feels
how she grows up day after day, and feels his movements and
heart beats until he comes to life with the ability of God.
Pregnant women should be aware of their health and balanced
diets at this stage, taking into account the high mortality rates
among pregnant women in the study community. At the same
time, with a moderate increase in weight during pregnancy, the
mother will have the opportunity to have a child Full-grown and
strong, while minimizing the risk of postpartum health
problems. Reduces the risk of anaemia and iron deficiency in
pregnant women. Fatigue and poor immunity to colds, infections
and rapid changes in mood are caused by iron deficiency, so
when pregnant women eat foods rich in iron, they can avoid the
symptoms of this deficiency. Provides the holder with the

energy needed to have a healthy child. Accelerates the process
of recovery after delivery. Healthy food is necessary for the
recovery and recovery of the body after the birth of the child,
where the mother's body will need maximum energy and food
sources to heal the wound (Musaiger, 2013).
The study will provide vital information to organization whose
main role is to promote good health in the country. These health
organizations will use research information in such areas as
decision making. In any case for instance the study will
determine that most young pregnant women in Saudi are not
aware about the type of diet that they need to maintain when
pregnant, health promotion organizations will be compelled to
begin conducting public campaigns aimed at teaching the
women around the country about the diet that they need to
maintain during this vital time (Serenius, 2015).
In addition, the study results will provide a basis for conducting
further studies in the topic of nutrition. This is more likely to
happen if other researchers will discover the ideas that the
research study did not tackle. Future researchers for instance
may decide to conduct a study aimed at determining the regions
with poor nutritional education. The importance of being more
specific in terms of region in this case is that it will direct
health promotion organization on places to put more effort. It
will be unhelpful for example for health promotion
organizations to focus on areas whose inhabitants have high
nutrition education and leave those areas whose inhabitants
have low nutritional education (Al Arfaj, 2014).Aim of the
Study
The aim of the study is to identify nutrition knowledge among
young pregnant women.Objective
1. To determine the current state of Nutrition knowledge among
young pregnant women in Saudi Arabia
2. To raise awareness Nutrition knowledge among young
pregnant women Saudi Arabia
3. To increase awareness of nutrition knowledge among young
pregnant women Saudi ArabiaResearch Question

1. What is the current state of Nutrition knowledge among
young pregnant women in Saudi Arabia?
2. How it can increase awareness of nutrition knowledge among
young pregnant women Saudi Arabia?
3. What type of food are you supposed to eat when
pregnant?Chapter 2Design
Research design refers to a set of procedures and methods used
to collect and analyze measures that have been specified in a
research problem. The research design for this study will be
both quantitative and descriptive. The quantitative part will
involve the use of mathematical, statistical and computational
tools to examine the collected data. Mathematical tools for
instance will be used to determine the percentage of women that
have the needed nutritional knowledge for pregnant mothers.
The percentage figure of women with this knowledge will be
subtracted from the 100 to get the percentage of women that
lack this critical knowledge. Statistical tools in this case may be
used to determine the average number of pregnant young women
with the needed nutritional knowledge (Mufti, 2016).
The descriptive part will involve narrating the characteristics of
the young pregnant Saudi women. In any case the study for
instance will determine that most of the women that do not have
the needed knowledge are mainly those from poor background;
this will be described as; poverty hinders many young pregnant
Saudi women from accessing vital information about diet.
Better still, in any case the study will establish that most
expectant women that have the needed nutritional knowledge
are from wealthy background, this will be described as;
pregnant women from rich background are more mindful about
what they eat during the time of pregnancy (Abdel 2015).
One of the benefits of the above research design is that they
will help during the suggestions of observations. In any case it
will be observed for instance that most pregnant young Saudi
women are not willing to educate themselves about the right
nutrition that they need during pregnancy, this will be recorded
down on paper that; despite nutrition being a key factor in the

health of the fetus and the pregnant young Saudi women, quite a
number of these expectant mothers do not still see the
importance of the measures. It is important to note here that this
will be mainly be about recording what has been find out
(Kromhout, 2017).
Second, the above research design will be helpful in pinpointing
analytical and statistical procedures. The initial step during
analysis exercise will be organizing the data and then creating
such figures as pie charts. The creation of pie charts will
require mathematical skills especially when determining the
proportions of the pie chart. The created pie chart in this case
will be analyzed and facts about what is being observed
recorded down. The significance of recording facts in this case
is that it will help in providing a basis on which conclusions
will be made. The main aim in this case will be to come up with
the correct facts (Jannadi, 2016).
Additionally, the above research design will be used to pinpoint
the independent and dependent variable. The independent
variable in this case for instance is pregnant women while the
dependent variable is nutritional knowledge. The implication is
the independent variable in this case is that only young pregnant
Saudi women will be interrogated. The already specified age of
the participants is women aged between 12 and 25 years. The
implication of the nutritional knowledge in this case is that not
all expectant young Saudi women are expected to have the
needed nutritional knowledge. Some pregnant young women
will have this knowledge while others will be lacking this
critical knowledge (Ghanim, 2016).Setting
The setting of any research study refers to the area place that
the study will be conducted. This study will be conducted in
Eastern Province of the Kingdom of Saudi Aribia. The specific
health facilities in which the study will be carried out in
Almana Medical Center. It is equipped with the latest and best
medical equipment for patient services. It has a capacity of over
1100 beds. The city has four hospitals that treat more than
700,000 patients. . The study will mainly be conducted in

maternity wards. This particular setting has been selected for
the reason that it is the only place that has a guarantee of
meeting pregnant women. In any case the study was to settle on
residential settings, the number of pregnant women that will be
accessed will be low. As a matter of fact, not all residential
places have expectant young women. Maternity wards offers the
best setting to conduct the study for the reason that it is where
most pregnant women assemble to get the care that they need or
deliver babies.
Young pregnant women coming for checkups will also be
interrogated. This refers to those women whose pregnancy is
still at early stage that do not require admission to hospital. The
planned study will focus of three hospitals. The specific unity
of the hospital that this study will be mainly conducted is the
maternity ward. Upon obtaining information from one hospital,
the study will be moved to the second and third hospital in that
order. The main thing he will be to get access to the maximum
number of women possible.Sampling and Population
Sampling refers to the process of picking out individuals from
the larger population for measurement reasons. A simple
random sampling method will be used when selecting the many
young pregnant women in maternity wards (Bakhotmah, 2016).
While inside the maternity wards, Young pregnant women will
be picked randomly. This will be favored more by the fact that
the women in most maternity wards are never arranged in a
particular order. The process of picking and interviewing the
pregnant women will be done at a time when the nurses and
physicians have finished attending to these individuals. The
main reason for this is that it will help prevent interruption
(Abuya, 2014). The expected confidence rate is 95% while the
anticipated error margin will be 5%.
Inclusion Criteria
Expectant women that will be included in the study are those
aged between 12 and 25 years. Women above the age of 25
years will not be included in the study.

Exclusion Criteria
Expectant women that will be found to deliver unbelievable
information will be excluded from the study.
The study looks forward to interviewing a total population of
200 pregnant young women aged between 12 and 25 years. This
figure will not be from one hospital but rather it will be from all
the three hospitals that have been selected for the study. The
study aims at interrogating an average of 67 women per a
hospital (Contento, 2013). One of the reasons as to why it is
important to interview young pregnant women in different
maternity hospitals is that it will help in determining the
reliability of information of the information obtained. This is
especially when it comes to consistency (Al-Almaie, 2013).Data
Collection
Data collection typically refers to the activity of gathering as
well as measuring information pertaining variables that have
been identified to be of interest. One of the methods that will
be employed during data collection will be interviews.
Typically, the interview session in this case will involve asking
the young pregnant Saudi women some questions. The questions
in this case will be those designed to establish whether this
individuals have the needed nutritional knowledge for pregnant
mothers. The answers that the pregnant young women will be
providing during the interview will be immediately recorded.
This is for the reason that it will be difficult to remember all the
answers after conducting various interviews. The interviews
will be conducted for a very short time to avoid time wastage.
Information will be collected from young pregnant Saudi
women aged between 12 and 15 years (Al-Mazrou, 2016).
A few of the advantages of using interviews include the fact
that they enable a researcher to obtained detailed information
and also the fact that it enables the researcher to observe non
verbal cues. When conducting interviews, young pregnant will
be asked a few questions after which they will be allowed to
provide answer. As these women will be providing the answers,

interruption will be greatly avoided. The main aim of this will
be to allow them to provide detailed answers (De Vriendt,
2016).The question will be self-develop based on related liter
Another method that will be employed during the study is the
questionnaire method. Both open-ended (7 questions) and closed
(3) question will be asked. a total of This method will involve
issuing printed questions to the pregnant young Saudi women in
the maternity wards and also those that will be coming for the
tests. The questions will be issued to those expectant mothers
that are waiting to see the doctor. No question will be issued to
expectant mothers that are already in labor pain. This is because
they will not have time to respond to the questionnaires. To
make this method consume less time, questions with multiple
answers choices will be used (Kirby, 2015).
Some of the advantages of using questionnaires include the fact
that they lead to speedy answers and also the fact that they are
cost effective. Unlike in the case of interviews, respondents
answering the questionnaires will not be required to give
detailed answers. This is especially if the questions asked only
require them to select the best option among the ones that will
be provided. The benefit of getting speedy answers in this case
is that it will help avoid time wastage (Siddiqui, 2013).Ethical
Considering
The first step towards collecting information will be to seek
permission from the hospital management board. Personal
information such as the real names of the young pregnant
women will be made anonymous to avoid legal problems
(Walston, 2013). The purpose of doing this will be to prevent
mockery from the society. Young girls that have for instance
become mothers may be mocked for engaging in sexual activity
at an early age. Given the fact that Saudi Arabia is a religious
country that expects high moral standards, people may refuse to
associate with the young girls that became pregnant at an early
age. This is common due to the belief that individual that
engage in immoral activities are not good to associate with
(Williams, 2014).

Other than concealing personal information, the research will
avoid asking the participants questions about private
information (Halligan, 2015). A good example of a question that
could be too personal is that asking about the name of the father
of the unborn child. The disadvantage of asking for private
information in this case is that it will influence the young
pregnant women to change their attitude. A complaint from one
young pregnant woman might discourage the rest from allowing
them to be interrogated. This could be as a result of the
mentality that they might also be asked the annoying questions
that the others have been asked (Srivastava, 2015).
One more ethical factor that will be considered during the study
is informed consent (Al‐Hafedh, 2016). What informed consent
here means is that the pregnant young Saudi women will be
asked for permission before the process of interrogating them
starts. The study recognizes the fact that not all women may be
willing to be interrogated. One of the reasons for this could be
stress about pregnancy complications. Women for example that
have been informed that they will not deliver through the
normal way might be stressed about the procedure that they
might be about to undergo (Young, 2017).
Participants will be treated with kindness and any form of
wrongdoing against them will be highly avoided. The
significance of treating participants with kindness in this case
will be a way of showing them that their contribution is being
appreciated. Being rude to them will make them to change their
attitude. Wrong doing in this case might include falling the
luggage belonging to the expectant women. Like in this case of
being unkind, this will influence negative attitude (Halligan,
2015).Pilot Study
A pilot study refers to an initial study conducted in order to
explore issues surrounding the planned study. The main reason
for this pilot study is to prepare for the issues. Preliminary
study will be conducted prior the main study. One of the main
reasons for this will beto determine the actual cost and time of
the study (Khan, 2017). One of the benefits of knowing the

exact cost of the study is so as to avoid the inconveniences of
underestimations. The impact of underestimation for instance is
that it might suddenly bring the study into a standstill when the
available funds get over. Situations such as these make it
difficult for a study to continue. The importance of knowing the
correct time estimates is to avoid time wastage (Farghaly,
2013).
Another reason for conducting preliminary study will be so as
to determine whether there are adverse events and make
necessary preparation. One of the adverse events that will be
considered in this case are whether events such as heavy rain. It
will be determined during the pilot study that the areas of study
are currently experiencing heavy rainfall, a resolution will be
made to carry warm clothing during the day of the study. The
reasoning behind this is that it is difficult to carry out carry out
a research perfectly when one is feeling uncomfortable (El-
Gilany, 2013).
Validity & Reliability
Validity as applied to research refers to the level to which a
data being obtained is believable. Validity during the research
will be ensured through evaluating the information being
provided to establish whether it is believable. In any case it will
be determined that some young pregnant women are not
providing believable information, the information that they will
have provided will be rejected (Al‐Majed, 2014).
Reliability as applied in research refers to the ability of a
measurement tool producing consistent results. Reliability
during the study will be ensured through repeating certain tests
to establish whether they are providing consistent results. In
any case it will be established that the repeated tests do not
provide consistent results, this will be taken to mean that the
results obtained are not reliable. What will be done in this case
is that the tests will be repeated until that time when there will
be consistency (Hijazi, 2014).
The significance of obtaining valid and reliable data is that it
will lead to lead to genuine conclusion. This is the main reason

as to why the study will exclude any participant that will be
found to provide unbelievable information. During the study,
participants will be told that the data that they provide will be
used to make important decisions aimed at improving the
maternal health care in the country. The pregnant young
mothers will be assured that their true identity will not be
revealed. The importance of this prior notification is that it will
influence the young pregnant mothers to give genuine
information (Pötzsch, 2016).
Genuine conclusion from this research will help health care
organization to make good decisions. In any case the study for
instance will by mistake come to the conclusion that most
women have the needed nutrition knowledge pertaining
pregnancy, this will make health promotion organizations to
relax their effort of educating young pregnant women about the
appropriate diet that they need to feed on. The likely impact of
this is that it will worsen the existing problem. This is
especially if the truth of the matter is that most pregnant young
women do not have the needed knowledge pertaining nutrition
(Unicef, 2015).Data Analysis
The process of analyzing data will after the information will
have been entered into the computer system (Desjeux, 2014).
One of the software that will be used to analyze data is the
SPSS data analysis tool. This particular software will be mainly
used to perform statistical operation. The software for instance
will be used to calculate the percentage of the women that have
nutritional knowledge concerning the diet that pregnant women
need to feed on. The significance of using this software here is
that it will help save time. This is for the reason that this
software performs statistical operations faster when compared
to when the operations are done manually (Littlewood, 2016).
The analyzed data will then be electronically stored in the
computer and backed using IT techniques (Sack, 2017). One of
the advantages of electronic storage of data is that data is
protected from physical damage. The use of physical files to
store data makes it to be subjected to expose to damages that

may for instance result from splash of water (Scholl, 2014). The
impact of splashing water on the physical files is that the water
dissolves the ink that was used to record the information
thereby deleting the information. The importance of backing the
store information is so as to ensure that the information stored
does not get lost in any case the computer gets damaged. Online
backing of the stored information will make it easier to access
the information from any point (Allen, 2015).Procedure of the
Main Study
This study will be in Almana medical center The researcher will
take his approval from King Fahd Hospital as well as from the
Saudi Research Council or the international period of three to
four weeks the study will be conducted for one week time after
five days of preparation. The initial step which is problem
definition will involve giving clear explanation about the
existing issue that the study is trying to investigate. The issue
that this study is trying to investigate is the inquiry to
determine whether young pregnant Saudi women have the
needed knowledge pertaining nutrition. This is due to the fact
that the nourishment that an expectant woman gets determines
the nutrients that the fetus gets. What this means is that poor
nutrition will make the fetus and the mother to lack essential
nutrients needed for development.
The second step which is Development of Research Plan will
involve scheduling all activities that will be required to be
undertaken for the goals and objectives of the projects to be
realized. The significance of scheduling all the activities is that
it will prevent the possibility of forgetting some activities.
Assigning time to each activity will make the process of
estimating the total time that the study needs. The advantage of
doing this is that it will prevent the problem of time wastage.
This will be by ensuring that study does not involve activities
not listed in the schedule.
Pilot Study which is the third step will involve carrying out a
preliminary study and that is take (1 month). This will entail
exploring all areas of the study to establish surrounding issues.

A few of the things that will be examined during this
examination include the cost and time of the study. The
estimated costs will be evaluated to determine whether they
have been overestimated or underestimated. The impact of
overestimating costs is that it leads to wastage of financial
resources. The effect of underestimating costs is that it will
increase chances of the project coming into a standstill should
the funds run out.
The fourth step which is Collection of Data will involve going
to the hospital (Almana Medical Center) they take 2 to3 month
to gather information. The specific place in the hospital that
information will be collected from will be materiality wards. In
the maternity wards, expectant mothers will be interrogated to
determine whether they have nutrition knowledge concerning
the type of food that pregnant women need to eat. Upon
collection, data will be organized and then stored electronically
in the computers. The stored data will be backed up so that it is
not lost
The next step which is analysis of collected data will involve
examining the data. To do this, the stored data will have to be
first retrieved. Next after retrieving the data, the examination of
this data will entail trying to establish whether there are trends
in the data. An example of a trend that may be identified is a
case where the types of women that have the needed nutritional
knowledge are those that come from wealthy backgrounds. All
the existing trends in the data will be listed and then
concussions generated.
The final step which is reporting analysis result will involve
giving an account of the whole activity. That is take 1 month.
They report that will be written in this case will have four
chapters. The last chapter will contain the results from the study
conducted. Other than containing the results of the study, this
particular chapter will highlight conclusions that have been
made from the study that has just been conducted.
Chapter 3Time Scale

Time Scale
The mission
The expected time
Write the Literature review
(2) Weeks
Conducting Pilot study
(1) Month
Take a Study approval
(3-4) Weeks
The Data collection
(2-3) Months
Analysis the data
(3-4) Months
Writing the Result
(2) Months
Reviewing
(1) Month
participants
(1) Month
The Total
12 months and 2 weeks
The total estimated time for completion of this research project
and work on publication is one year with two weeks divided as
follows from three to four weeks to choose the hospital and the
Board of Audit also 4 weeks to conduct the pilot study until the
research is improved Data collection takes two to three months
while analyzed Within three months the result will be two
months.
Budget
The researcher will cost many related to using laptop, printer,
printer inks, pens, notebooks, MAXQDA software, papers, pilot
study, files, transportation, and Telephone bills. The cost for

these items as the following:
Item
Cost
Laptop
3000 RS.
Printer
400 RS.
Printer inks
500RS.
Pens
150 RS.
Notebooks
50 RS.
Files
200 RS.
Papers
400 RS.
Pilot study
500 RS.
MAXQDA software
1000 RS.
Transportation
2000 RS.
Telephone bills
500 RS.
Total budget
8700 RS.
The significant of a budget in this case is that it will help
ensure that funds allocated for this project are spent for their
true purpose. This means that the budget will prevent purchase
of items that have not been planned. Second, this budget will

help increase accountability. To be accountable in this case
means being answerable to all the expenditure that has been
incurred. This is especially if money at one point in time during
the study will be used for a wrong purpose.
In addition, this budget will be useful in saving some money
that might not be used during the study. This is for the reason
that there are high chances that the some items might cost lower
than has been estimated. The total of papers in this case for
instance will depend on the shop from which they are being
bought. Even though the estimated cost is 400 RS, this cost
might be lower if the papers will be bout from a shop that is
selling this item at a lower cost. The cost of this item might
even be lower if the shop will be offering discounts during the
time of purchase. Expected Outcome
The importance of balanced nutrition for the pregnant woman
must pay attention to her5 health and the adoption of balanced
food systems during this stage and we will mention the
following types of foods that are recommended to eat at each
stage of pregnancy, in addition to some tips and guidance on
foods to avoid during pregnancy.
So it must. It is essential for pregnant women to pay attention
to their health and to follow a balanced diet. During this stage,
we will mention the types of foods that you are advised to eat at
each stage of pregnancy, as well as some tips and advice
regarding foods to avoid during pregnancy.
To conclude the purpose of the study is to investigate and
establish whether pregnant young Saudi women have the needed
nutritional knowledge. Nutrition knowledge in this case refers
to information and skills that an individual normally has
pertaining food intake. In respect to the research topic, this
refers to information and skills needed by pregnant young Saudi
women. Nutrition plays a key role during pregnancy in the sense
that the nourishment that a pregnant woman gets determines the
nutrients that the developing fetus gets. The study will assess
women aged between 12 years and 25 years. A few of the
factors that contributed to early pregnancies include poverty

and separation of parents through divorce.
References
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19. De Vriendt, T., Matthys, C., Verbeke, W., Pynaert, I., & De
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young and middle-aged Belgian women and the association with
their dietary behaviour. Appetite, 52(3), 788-792.
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25. Halligan, P. (2015). Caring for patients of Islamic
denomination: critical care nurses’ experiences in Saudi
Arabia. Journal of clinical nursing, 15(12), 1565-1573.
26. Hijazi, N., Abalkhail, B., & Seaton, A. (2014). Diet and
childhood asthma in a society in transition: a study in urban and
rural Saudi Arabia. Thorax, 55(9), 775-779.
27. Jannadi, B., Alshammari, H., Khan, A., & Hussain, R.
(2016). Current structure and future challenges for the
healthcare system in Saudi Arabia. Asia Pacific Journal of
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28. Khan, M. A., & Al Kanhal, M. A. (2017). Dietary energy
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29. Kirby, D. (2015). Sexuality education: a more realistic view
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30. King, J. C. (2016). The risk of maternal nutritional
depletion and poor outcomes increases in early or closely
spaced pregnancies. The Journal of nutrition, 133(5), 1732S-
1736S.
31. Kromhout, D., Keys, A., Aravanis, C., Buzina, R., Fidanza,
F., Giampaoli, S., ... & Pekkarinen, M. (2017). Food
consumption patterns in the 1960s in seven countries. The
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33. Madani, K. A., Al-Amoudi, N. S., & Kumosani, T. A.
(2015). The state of nutrition in Saudi Arabia. Nutrition and
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35. Mansour, A. A., & Hassan, S. A. (2014). Factors that
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AppendixAppendix I
Consent Form
I …………… give permission to …………………………… so
that he can to interrogate me about the subject of nutrition
knowledge. I understand that the study will require me to
provide brief statements and I am willing to do this.
I do understand that my participation in this study is Voluntary.
I also understand that the study personnel have power to stop
my participation at his will.
Participant’s Signature ……………………………….
Date…………………………………
I confirm that I have explained to the participant what the study
is all about. I confirm that I understand the principle of
confidentiality that I am required to honor. I confirm that I have
promised the above named person that I will not reveal her
private information to another person whatsoever.
Investigator’s Signature
…………………………………Date………………………………...
Appendix II Participant Leaflet
Information leaflet:
Title of this study: The Nursing Perception and the Impact of
Providing a Holistic Nursing Care for Critically Ill Patients
Name of the student researcher: Alreem Ali
This study explore the Nutrition Knowledge among Young
Pregnant Women in Saudi Arabia . I am interested to know the
level of awareness of these women This study will conduct in
the Almana Medical Center in Al-Khobar. The aim of this paper
is to gain your permission to start the research by collecting the
information from the interview questions. This research will use

a strategy of valid self-administered and semi structured
interview questions in English language.
Aim of the study: The aim of the study identify nutrition
knowledge among young pregnant women.
Research design: quantitative design
Participation: young pregnant women in maternity wards in
Almana Medical Center
Sampling: 200 pregnant young women aged between 12 and 25
years
Contact details
Researcher name:
Phone number:
Email:
Appendix III
Questionnaire
Part one (Social Demography Data)
· What is your age?
A. 12-16 years
B. 17-21 years
C. 22-25 years
· What is your level of education?
A. Primary
B. Secondary
C. College
· Are you married or single?
A. Married
B. Single
Part two (Pregnancy)
· How old is your pregnancy?
A. 0-3
B. 4-6
C. 7-9
· What is the gender of your unborn little baby?

A. Male
B. Female
· Are you expecting twins?
A. Yes
B. No
C. Maybe
· Is this the first pregnancy?
A. Yes
B. No
· How can you describe the pregnancy experience?
A. Good
B. BadPart three (Nutrition)
· Which of the following fruits are you supposed to avoid when
Pregnant? (Tick all)
A. Apricots
B. Tamarind
C. Papaya
D. Pears
E. Dates
· Which of the following vegetables are you supposed to avoid
when Pregnant? (Tick all)
A. Legumes
B. Raw Eggs
C. Sweet Potatoes
D. Caffeine
E. Raw Fish
· Which of the following beverages are you supposed to avoid
when Pregnant? (Tick all)
A. Orange Juice
B. Unpasteurized Milk
C. Alcohol
D. Low Fat Milk
E. Wheat Grass
· Are bananas appropriate for eating during pregnancy?
A. Yes
B. No

· Is coconut water appropriate for drinking during pregnancy?
A. Yes
B. No
· Are watermelons appropriate for eating during pregnancy?
A. Yes
B. No
31
Articles
www.thelancet.com Vol 367 June 3, 2006 1819
Caesarean delivery rates and pregnancy outcomes: the 2005
WHO global survey on maternal and perinatal health in
Latin America
José Villar, Eliette Valladares, Daniel Wojdyla, Nelly Zavaleta,
Guillermo Carroli, Alejandro Velazco, Archana Shah, Liana
Campodónico,
Vicente Bataglia, Anibal Faundes, Ana Langer, Alberto
Narváez, Allan Donner, Mariana Romero, Sofi a Reynoso, Karla
Simônia de Pádua,
Daniel Giordano, Marius Kublickas, Arnaldo Acosta, for the
WHO 2005 global survey on maternal and perinatal health
research group*
Summary
Background Caesarean delivery rates continue to increase
worldwide. Our aim was to assess the association between
caesarean delivery and pregnancy outcome at the institutional
level, adjusting for the pregnant population and

institutional characteristics.
Methods For the 2005 WHO global survey on maternal and
perinatal health, we assessed a multistage stratifi ed
sample, comprising 24 geographic regions in eight countries in
Latin America. We obtained individual data for all
women admitted for delivery over 3 months to 120 institutions
randomly selected from of 410 identifi ed institutions.
We also obtained institutional-level data.
Findings We obtained data for 97 095 of 106 546 deliveries
(91% coverage). The median rate of caesarean delivery was
33% (quartile range 24–43), with the highest rates of caesarean
delivery noted in private hospitals (51%, 43–57).
Institution-specifi c rates of caesarean delivery were aff ected
by primiparity, previous caesarean delivery, and
institutional complexity. Rate of caesarean delivery was
positively associated with postpartum antibiotic treatment and
severe maternal morbidity and mortality, even after adjustment
for risk factors. Increase in the rate of caesarean
delivery was associated with an increase in fetal mortality rates
and higher numbers of babies admitted to intensive
care for 7 days or longer even after adjustment for preterm
delivery. Rates of preterm delivery and neonatal mortality
both rose at rates of caesarean delivery of between 10% and
20%.
Interpretation High rates of caesarean delivery do not
necessarily indicate better perinatal care and can be associated
with harm.
Introduction
Rates of caesarean delivery have risen from about 5% in
developed countries in the early 1970s1–5 to more than
50% in some regions of the world in the late 1990s.6
Many factors have contributed to this rise, including

improved surgical and anaesthetic techniques, reduced
risk of post-operative complications, demographic and
nutritional factors,7,8 providers’ and patients’ perception
of the safety of the procedure,9 obstetricians’ defensive
practice,10 changes in health systems,11 and patient
demand.12,13 Caesarean delivery is thought to protect
against urinary incontinence, prolapse, and sexual
dissatisfaction, increasing its appeal.14,15 Finally, the rise
in numbers of women opting for a caesarean might also
be aff ected by obstetricians’ defence of women’s rights
to choose their method of delivery.16
Medical strategies, such as mandatory second opinion
before doing a caesarean section, have not reduced the
numbers of caesarean deliveries,17 and a randomised
trial to compare perinatal outcomes and satisfaction of
caesarean delivery on demand for all women versus
caesarean delivery only when clinically indicated is
being contemplated.18 Before such practice can be
assessed and an appropriate trial designed, however, the
optimum proportion of caesarean deliveries for any
particular institution, based on the risk profi le of that
institution’s pregnant population, needs to be
identifi ed.13,19,20
Our aim was to assess the association between rates of
caesarean delivery and maternal and perinatal outcomes
at the institutional level.
Methods
Population
We designed the 2005 WHO global survey on maternal
and perinatal health to explore the relation between
rates of caesarean delivery and perinatal outcomes in
the medical institutions of eight randomly selected

countries in the region of the Americas, using a
multistage stratifi ed sampling procedure. We obtained
data between Sept 1, 2004, and March 30, 2005.
After country selection, we identifi ed a representative
sample of geographic areas within each country and,
within these geographic areas, a representative sample
of care units. We selected countries with a probability
proportional to the population of the country, provinces
with a probability proportional to the population of the
province, and health institutions with a probability
proportional to the number of deliveries per year. Here,
we present results from the eight countries in Latin
Lancet 2006; 367: 1819–29
See Comment page 1796
Published Online
May 23, 2006
DOI:10.1016/S0140-
6736(06)68704-7
*All listed at end of report
UNDP/UNFPA/WHO/World
Bank Special Programme of
Research, Development and
Research Training in Human
Reproduction, Department of
Reproductive Health and
Research, WHO, 1211 Geneva
27, Switzerland (J Villar MD,
A Shah MSc); Universidad
Nacional Autónoma de
Nicaragua, León, Nicaragua

(E Valladares MD); Centro
Rosarino de Estudios
Perinatales, Rosario, Argentina
(D Wojdyla MSc, G Carroli MD,
L Campodónico MSc,
D Giordano BS); Instituto de
Investigación Nutricional,
Lima, Peru (N Zavaleta MD);
Hospital Docente
Ginecobstétrico “América
Arias”, La Habana, Cuba
(A Velazco MD); Department of
Obstetrics and Gynecology,
Hospital Nacional de Itauguá,
Paraguay, Asunción, Paraguay
(V Bataglia MD); Centro de
Pesquisas em Saúde
Reprodutiva de Campinas,
Campinas, SP, Brazil
(A Faundes MD,
K Simônia de Pádua BS);
EngenderHealth, New York,
NY, USA (A Langer MD);
Fundación Salud, Ambiente y
Desarrollo, Quito, Ecuador
(A Narváez MD); Department of
Epidemiology and
Biostatistics, Schulich School of
Medicine and Dentistry,
University of Western Ontario,
London, Ontario Canada
(A Donner PhD); CONICET/
Centro de Estudios de Estado y
Sociedad, Buenos Aires,
Argentina (M Romero MD); The
Population Council, Latin

America Offi ce, Mexico City,
Mexico (S Reynoso MD);
Karolinska Institutet,
Stockholm, Sweden
(M Kublickas MD); and
Department of Obstetrics and
Gynaecology, Universidad
Nacional de Asunción,
Paraguay, Asunción, Paraguay
(A Acosta MD)
Correspondence to: Dr José Villar
[email protected]
Articles
1820 www.thelancet.com Vol 367 June 3, 2006
America; we will report results of a similar survey done
in Africa separately. In 2006, we will prepare the survey
for Asia and Canada.
We initially stratifi ed each country by its capital city
(always included) and two other randomly-selected
administrative geographic areas (provinces or states).
Within these three areas, we undertook a census of
hospitals that reported more than 1000 deliveries in the
previous year. We then stratifi ed data by province or
state, choosing a representative sample of up to seven
institutions each. If there were seven or fewer eligible
institutions, we included them all. We included all
women admitted to the selected institutions for delivery
during a fi xed data collection period of either 2 or
3 months, depending on the total number of expected

deliveries per institution for the complete year (3 months
if ≤6000 per year; 2 months if >6000 per year).
We did not obtain individual informed consent from
women, since ours was an institutional-level analysis;
we obtained all individual-level data from medical
records and did not identify participants. Institutional
informed consent was obtained from the responsible
authority of the participating health facilities. The
ethical committee of WHO and of each country, as well
as those of all hospitals in Brazil and some of the large
hospitals in Mexico and Argentina, independently
approved the protocol.
Procedures
We collected data at two levels—institutional and
individual. At the institutional level, we gathered data on
one occasion only, with the aim of obtaining a detailed
description of the health facility and its resources for
obstetric care. The country or regional coordinator fi lled
in a form during a visit to the institution, in consultation
with the hospital coordinator, director, or head of
obstetrics. At the individual level, we obtained from all
women’s medical records information to complete a
two-page pre-coded form, summarising obstetric and
perinatal events. Trained staff reviewed the medical
records of all women within a day after delivery and
abstracted data to their individual data collection forms,
which were completed during the period that the woman
and newborn baby remained in hospital. A nurse or
midwife working on the labour or postpartum ward at
each institution was responsible for data collection on a
day-to-day basis. A hospital coordinator supervised data
collection, resolving or clarifying unclear medical notes
before forms were sent for data entry. Attending staff
updated incomplete records before discharge.

We used the individual-level form to obtain information
about demographic characteristics, maternal risk,
pregnancy events, mode of delivery, and outcomes up to
hospital discharge. The institutional-level form was used
to obtain data on characteristics associated with maternal
and perinatal care and outcomes, including: laboratory
tests; details of anaesthesiology resources; services for
intrapartum care, delivery, and care of the newborn
baby; and presence or absence of basic emergency
medical and obstetric care facilities, intensive care units,
and human and teaching resources. Criteria for data
abstraction were defi ned in the manual of operations,21
which was also available for training staff and monitoring
data quality, reducing to a minimum the need for
judgment and interpretation. The manual contained
defi nitions of all terms used and synonyms of medical
and obstetric terms, and described questions and
precoded corresponding answers. We pretested both
data forms in four countries during July and August,
2004.
We classifi ed caesarean deliveries as: a) emergency, if
the woman was referred before onset of labour with a
diagnosis of acute fetal distress, vaginal bleeding, uterine
rupture, maternal death with fetus alive, or eclampsia;
b) intrapartum, if indicated during labour, whether labour
was spontaneous or induced; c) elective, if decision to do
the operation was made before onset of labour and the
woman was referred either from an antenatal clinic or a
high-risk ward (if the timing of the decision was unclear,
we did not identify as elective those caesareans done in
women whose labour had been induced or those done in
women who received anaesthetic during a spontaneously
initiated labour).

We recorded the following perinatal outcomes as
potentially aff ected by caesarean delivery: intrapartum
8 countries in Latin America included—Argentina,
Brazil, Cuba, Ecuador, Mexico, Nicaragua,
Paraguay, Peru (24 geographic units, covering
the capital city and two randomly selected
provinces in every country)
1 province in Paraguay excluded
because did not have facilities
for >1000 births per year
410 facilities identified
in 23 geographic units
3 facilities refused to participate
123 facilities randomly selected
120 facilities included
(4 facilities with restricted
recruitment period because
of logistical problems)
35 countries in America region
11 of 35 randomly selected
2 countries did not participate—Haiti
and USA
1 country to start recruitment in
2007—Canada
Figure 1: Trial profi le

For the study protocol and a
detailed description of the
selection process see http://
www.medscinet.com/who
Articles
fetal death, preterm delivery (<37 weeks), admission to
neonatal intensive care unit for 7 days or longer, and
neonatal death before hospital discharge of the newborn
baby. We assessed maternal morbidity with proxy events,
mostly severe conditions, rather than the clinical diagnosis
itself, because of problems in standardising defi nitions.
For example, we assumed that blood transfusion and
hysterectomy indicated severe postpartum haemorrhage;
maternal admission to an intensive care unit, maternal
death, or maternal hospital stay for longer than 7 days
denoted severe complications. We constructed a summary
index—severe maternal morbidity and mortality index—
if at least one of the above complications was present and
used it as the primary maternal morbidity outcome. We
assessed postpartum treatment with antibiotics (except
prophylactic) separately as an indicator of postpartum
infections. Third and fourth degree perine laceration and
postpartum fi stulae were also maternal outcomes.
We classifi ed health institutions as private or belonging
to the public-health system or the social-security system,
as reported by the institutions’ authorities. We included
state university hospitals as public institutions and all
labour-union hospitals as social-security institutions.

We classifi ed religious institutions according to the
patients’ main mechanism of payment. Most deliveries
in the areas studied are facility-based, with only a small
proportion of women having home deliveries.
Statistical analysis
The provincial or country coordinator of the survey checked
forms for completeness and accuracy, and any queries
were addressed immediately or in consultation with
coordinators. We collated all data via the internet at the
country coordinator level, using an online data management
system based on MedSciNet’s clinical trial framework
(MedSciNet, Stockholm, Sweden) in collaboration with
WHO. We calculated coverage of the survey by comparing
the number of forms completed during the study with the
number of deliveries recorded in the logbook of each
hospital. Analyses are based on institution-level variables,
with individual data aggregated by calculating proportions
per institution. We prepared a conceptual framework to
guide data analysis.
We developed a hospital complexity index, summarising
an institution’s capacity to provide diff erent levels of care,
depending on its ratings for eight categories: building,
general medical care, laboratory, anaesthesiology,
screening test, human resources, basic obstetric services,
and continuous medical education. For each category, we
identifi ed a set of minimum essential services or
resources; we classifi ed hospitals without any of these
services or resources as low level (rating score 0). For
most categories, we also identifi ed an additional set of
optional services or resources, classifying facilities that
had both essential and optional services or resources as
high level (rating score 2) and those that were lacking
some of the optional services or resources, but had all

essentials, as medium level (rating score 1). An overall
unweighted score (0–16) was calculated for all institutions.
We judged hospitals with a total score of 9 or less of low
complexity, those with scores of between 10 and 12 of
medium complexity, and those with scores of 13 or more
of high complexity. We recorded institutions as providing
0
10
20
30
40
50
60
70
80 Intrapartum
Emergency
Elective
Argentina Brazil Cuba Ecuador Mexico Nicaragua Paraguay
Peru
10
Pu
bli
c (

n=
74
53
)
4 P
riv
ate
(n
=3
29
5)
7 P
ub
lic
(n
=5
34
2)
1 S
oc
ial
se
cu
rit

y (
n=
29
4)
5 P
ub
lic
(n
=2
93
6)
1 S
oc
ial
se
cu
rit
y (
n=
58
9)
13
Pu

bli
c (
n=
12
64
2)
4 S
oc
ial
se
cu
rit
y (
n=
35
79
)
15
Pu
bli
c (
n=
12
64

3)
4 P
riv
ate
(n
=2
55
4)
14
Pu
bli
c (
n=
11
63
8)
2 S
oc
ial
se
cu
rit
y (
n=

65
2)
2 P
riv
ate
(n
=1
24
)
5 P
ub
lic
(n
=5
79
9)
15
So
cia
l se
cu
rit
y (

n=
14
62
8)
2 P
riv
ate
(n
=4
65
)
17
Pu
bli
c (
n=
12
64
2)
Pr
op
or
ti

on
c
ae
sa
re
an
d
el
iv
er
ie
s (
%
)
Figure 2: Proportion of elective, emergency, and intrapartum
caesarean deliveries done, according to type of
institution and country
Dotted line=median level for all institutions.
All
(n = 34266)
Public
(n=23020)
Social security
(n=8285)
Private

(n=2961)
Cephalopelvic disproportion, dystocia, failure to
progress
26% (8982) 25% (5792) 27% (2213) 33% (977)
Fetal distress 20% (6751) 21% (4805) 20% (1646) 10% (300)
Previous caesarean delivery without complications in
current pregnancy
16% (5305) 16% (3627) 13% (1110) 19% (568)
Previous caesarean delivery with complications in
current pregnancy
15% (5140) 14% (3223) 16% (1326) 12% (355)
Other pregnancy complications 12% (3968) 12% (2691) 10%
(845) 15% (432)
Breech or other malpresentations 11% (3620) 12% (2647) 9%
(778) 7% (195)
Pre-eclampsia or eclampsia 11% (3603) 10% (2248) 14% (1186)
6% (169)
Other fetal indications 9% (2926) 9% (1999) 9% (751) 6% (176)
Other medical complications 8% (2592) 8% (1816) 8% (620) 5%
(156)
Tubal ligation or sterilisation 6% (2015) 7% (1484) 6% (485)
2% (46)

Failure to induce labour 4% (1292) 4% (804) 4% (366) 4%
(122)
Intrauterine growth restriction 3% (959) 3% (646) 2% (186) 4%
(127)
Third trimester vaginal bleeding 3% (864) 3% (576) 3% (225)
2% (63)
Multiple pregnancy 2% (720) 2% (465) 2% (193) 2% (62)
Post-term (>42 weeks) 2% (627) 2% (443) 2% (148) 1% (36)
Genital herpes or extensive condyloma acuminata <1% (270)
<1% (206) <1% (54) <1% (10)
Suspected or imminent uterine rupture <1% (231) <1% (171)
<1% (54) <1% (6)
Postmortem caesarean section <1% (153) <1% (121) <1% (26)
<1% (6)
HIV positive <1% (126) <1% (102) <1% (10) <1% (14)
Maternal request without any other indication <1% (60) <1%
(31) <1% (3) <1% (26)
Previous repaired fi stula <1% (15) <1% (12) <1% (3) 0
Data are percentage (number). Sum of percentages in columns
exceeds 100% because some women had multiple indications.
Table 1: Indication for caesarean delivery, according to type of
institution
For MedSciNet see

http://www.medscinet.com/who
For more details of the
hospital complexity index see
http://www.crep.com.ar
Articles
an economic incentive to recommend caesarean delivery
if they charged their patients fees for delivery and
caesarean delivery was either more expensive than
vaginal delivery (institutional benefi t) or provided
additional income to the senior attending staff (staff
benefi t).
Indicators of the risk of the pregnant population served
by each institution (case mix) included the proportion of
women in the institution who: were aged 16 years or
younger or 35 years or older; had less than 7 years of
education; were single; were primiparous; had a history of
caesarean delivery, stillbirth, or neonatal death; had had
surgery on the uterus or cervix; had had a urinary or
gynaecological fi stula; or had any medical condition
diagnosed before the current pregnancy. We present
conditions diagnosed during the current pregnancy as
proportions of women in each institution with a multiple
pregnancy, gestational hypertension, pre-eclampsia,
eclampsia, vaginal bleeding in the second half of pregnancy,
condyloma acuminata, HIV, suspected impaired fetal
growth, or fetal malpresentation at term. We also note the
proportion of women in each institution who were referred

from other institutions, whose labour was induced, and
those who received an epidural during labour, all of which
we judged risk factors for caesarean delivery.
We assessed the crude associations between caesarean
delivery and risk factors with the Spearman correlation
coeffi cient. For each subgroup of variables related to
previous pregnancy, current pregnancy, and delivery, we
fi tted a multiple linear regression model22 to the individual
factors judged to be associated with caesarean delivery.
We considered signifi cant risk factors from these multiple
regression models as possible confounders of the
association between caesarean delivery and outcomes in
further analyses. We then added the hospital complexity
index, type of institution, and economic incentives for
caesarean delivery to the regression models.
The association between proportion of caesarean
deliveries and maternal and perinatal outcomes was
analysed with linear multiple regression models,22 with
these outcomes as the dependent variables and the
proportion of caesarean deliveries as the main independent
variable. We describe this relation graphically, using the
locally weighted scatter plot smoothing technique
(LOWESS).23 We added risk factors identifi ed in the above
algorithm to the models to estimate the independent
(adjusted) eff ect of caesarean delivery on maternal and
perinatal outcomes. For these analyses, the proportion of
outcomes and caesarean deliveries at each institution was
transformed to the logit scale, to improve normality.
Role of the funding source
External sponsors to WHO for this study had no role in
study design, data collection, data analysis, data
interpretation, or writing of the report. The corresponding
author had full access to all the data in the study and had

fi nal responsibility for the decision to submit for
publication.
Results
Figure 1 shows the trial profi le. The number of institutions
per geographic region ranged from six in Paraguay to 21 in
Mexico; deliveries per country ranged from nearly 3500 in
Paraguay to 21 000 in Mexico, and fi ve other countries
contributed more than 10 000 deliveries each to the sample.
Most of the health institutions were urban; 50 were
tertiary-level, 51 were district hospitals, 11 were primary-
care units with surgical facilities, and eight classifi ed as
other type of institution. 40 institutions had 70 or more
maternity beds, 44 had 30–69, and 36 had fewer than 30.
We included all 120 institutions in the regression analyses.
The average number of deliveries contributed by
Median
(%; 10th–90th percentiles)
Previous pregnancy
Marital status single 14·7 (4·1–63·0)
Age ≤16 years 4·0 (0·3–8·5)
Age ≥35 years 10·2 (5·4–17·1)
<7 years of education 24·5 (2·1–54·7)
Primigravidas 34·5 (22·6–42·7)
Primiparous 41·0 (30·7–50·3)
Previous child with low birthweight 3·3 (1·0–6·6)

Previous neonatal death or stillbirth 1·2 (0·3–2·4)
Previous fi stula or uterus-cervix surgery 4·6 (0·2–18·9)
Previous caesarean delivery 12·5 (4·3–20·6)
Current pregnancy
Any pathology before index pregnancy* 2·7 (0·4–12·1)
Any pathology during current pregnancy* 31·6 (14·9–50·0)
Gestational hypertension, pre-eclampsia, eclampsia 7·5 (2·4–
14·0)
Vaginal bleeding in second half of pregnancy 1·9 (0·8–7·2)
Urinary tract infection 11·1 (1·3–36·0)
Condyloma acuminate 0·3 (0·0–1·2)
Suspected intrauterine growth restriction 0·6 (0·0–3·1)
Other medical condition 5·4 (1·0–20·9)
Any antenatal antibiotic treatment 15·9 (2·7–41·4)
Birthweight >4·5 kg 0·40 (0·0–1·2)
Multiple pregnancy 0·8 (0·0–1·8)
Breech or other non-cephalic presentations 4·3 (1·5–7·3)
Delivery
Referred from other institution for pregnancy complications or

delivery 18·2 (0·8–79·6)
Induced labour 7·5 (1·7–25·7)
Epidural anaesthesia during labour 3·5 (0·1–55·2)
Caesarean delivery in present pregnancy 32·6 (15·7–51·8)
Characteristics of institutions
Institutional complexity index (range 0–16) 11 (8–13)
Public† 86 (71·7%)
Social security† 22 (18·3%)
Private† 12 (10·0%)
Economic incentives for caesarean delivery† 29 (24%)
*Includes pathologies of very low incidence not listed
independently.†Data are number (%) of institutions.
Table 2: Characteristics of populations served and health
institutions studied
Articles
institutions to the study population was similar across
countries, ranging from 588 deliveries per hospital in
Paraguay to 995 deliveries per hospital in Mexico.

The proportion of missing values at the individual level
was higher than 5% only for birthweight of previous
infant (23%), maternal height (17%), weight at last
prenatal visit (15%), and number of years of schooling
(5%). For all the primary variables—caesarean delivery
status, birthweight, gestational age, admission of
newborn baby to the neonatal intensive care unit, status
of baby and mother at discharge, and maternal admission
to intensive care—the proportion of missing values was
less than 1%.
Most of the hospitals were of medium complexity, with
a small number having either limited capacity (n=12) or
very complex resources (n=11). 12 hospitals were private,
and 86 belonged to the public-health system and 22 to
the social-security system. Among the 12 private
institutions, only one had a low complexity index,
compared with three of the 22 social-security institutions
and 25 of the 86 public-health hospitals. Seven of the
12 (58%) private institutions had evidence of economic
incentives for caesarean delivery, versus 5% (n=1 of 22) of
the social-security institutions and only 24% (n=21) of
public hospitals. 99% (33 915 of 34 228) of caesarean
deliveries and 63% (39 565 of 62 670) of vaginal births
were attended by obstetrician gynaecologists or residents.
Others were cared for by midwifes, medical or midwife
students, general practitioners, or nurses. 95% of women
who needed anaesthetic during labour or delivery were
given epidural or spinal preparations (80% of which was
provided by specialists in anaesthesiology).
Figure 2 shows caesarean delivery rates according to
elective, intrapartum, or emergency without labour, study
site, and type of institution. Overall, the median rate of
caesarean delivery was 33% (quartile range 24–43); 49%
were elective, 46% were intrapartum, and 5% were

emergency without labour. The proportion of caesarean
delivery was always higher in private hospitals (median
rate 51%; 43–57) followed by social security and public
institutions. Higher caesarean delivery rates in private and
social security institutions were mostly due to an increase
in elective caesarean delivery (fi gure 2). The rate of
caesarean delivery among nulliparous women, or those
without caesarean delivery in their previous birth, was
68% (n=22 972), ranging from 64% (n=1822) in private
institutions to 69% (n=15 768) in public ones (not included
in the fi gure).
Table 1 shows the indications for caesarean delivery. The
most common indication overall was cephalopelvic
disproportion/dystocia/failure to progress. Fetal distress
was the second most common indication in public and
social security institutions, whereas previous caesarean
delivery without any complication in the current pregnancy
was second in private institutions. Overall, 30% of women
undergoing a caesarean delivery had a history of previous
caesarean delivery. In social security institutions, pre-
eclampsia or eclampsia was the third most common
indication. Tubal ligation or sterilisation was the indication
in 6% of the caesarean deliveries at public and social
security institutions, but in 2% at private institutions.
Failure of labour induction was an indication for caesarean
delivery in about 4% of cases (table 1). Among women
whose labour was induced, a median of 28% across
hospitals (quartile range 18–40) went on to have a caesarean
delivery.
Table 2 shows baseline characteristics and details of
pregnancy and delivery. Furthermore, in an exploratory
analysis, we stratifi ed the results presented in table 2 by
rate of caesarean delivery—eg, low, medium, or high

rate, according to the tertile distribution of caesarean
delivery in this sample. We noted no clear risk pattern;
indeed, hospitals with a high rate of caesarean delivery
tended to have demographic and clinical variables
suggestive of lower pregnancy risk (though rates of
previous caesarean delivery concurred with those we
reported). Nevertheless, we adjusted for these baseline
variables in all multiple regression models included in
the tables.
Overall, also at the institutional level, maternal and
perinatal outcomes were typical for moderate-risk
pregnant populations. The median of the severe maternal
morbidity and mortality index in these institutions was
2% (quartile range 1–4), including haemorrhage with
Regression
coeffi cient*
Standard
error
p % variance explained
by each model†
Previous pregnancy
Age ≤16 years 0·013 0·0302 0·68 67%
Age ≥35 years 0·011 0·0154 0·47
<7 years of education 0·001 0·0047 0·78
Primiparity 0·069 0·0104 <0·0001
Caesarean delivery 0·142 0·0124 <0·0001

Current pregnancy
Gestational hypertension, pre-eclampsia, eclampsia 0·049
0·0196 0·01 20%
Vaginal bleeding in second half of pregnancy 0·011 0·0373
0·77
Multiple gestation 0·239 0·1638 0·15
Breech or other non-cephalic presentation 0·098 0·0296 0·001
Delivery
Referred from other institution because of
pregnancy complications or for delivery
0·008 0·0037 0·03 13%
Epidural during labour 0·018 0·0048 0·0004
Type of institution
Institutional complexity index 0·261 0·0448 <0·0001 34%
Economic incentive for caesarean delivery 0·329 0·2365 0·17
Public Reference
Social security 0·676 0·2615 0·01
Private 0·901 0·3306 0·007
*Obtained with multiple linear regression models with response
variable defi ned as logit transformation of proportion of

caesarean deliveries. All coeffi cients adjusted by other
variables in subgroups. †Adjusted for number of variables in
model
(adjusted R²).
Table 3: Association between proportion of risk factors,
according to institutions, and proportion of
caesarean deliveries (multivariable analysis)
Articles
blood transfusion (0·4%); hysterectomy (0·1%), maternal
hospital stay of longer than 7 days (0·7%) and maternal
death or admission to intensive care (0·2%). The median
rate of antibiotic treatment postnatally was 33% (19–52).
Third and fourth degree perineal laceration or
postpartum fi stula was reported in a median of 0·2%
(0·0–0·6). The median rate per thousand births of
intrapartum fetal death was 0·3 (0·0–0·8), for neonatal
death was 4 (1–7), and of staying 7 days or longer in the
neonatal intensive care unit was 19 (6–45); the rate of
preterm delivery was 6% (4–9).
We undertook a multiple linear regression analysis,
considering the proportion of caesarean deliveries in
each institution as the dependent variable, transformed
to the logit scale, while considering as independent
(explanatory) variables the proportion of pregnant
women in each institution with the risk factors for
caesarean listed in table 2. Primiparity, previous
caesarean, pre-eclampsia, breech or non-cephalic

presentation, referred from other institutions, and
epidural anaesthesia in labour were independently
associated with an increase in caesarean deliveries.
Institutions with a high complexity index, and private or
social-security institutions were also associated with
higher levels of caesarean delivery (table 3). Further
adjustments, taking into account the number of
deliveries contributed by each hospital, yielded similar
results (data not shown).
We included variables signifi cantly associated with
caesarean delivery in table 3 in a fi nal linear regression
model to assess their independent eff ects. The only three
criteria that remained positively signifi cant were
primiparity, caesarean delivery in previous pregnancy, and
the institutional complexity index, explaining 72% of the
variance in overall rates of caesarean delivery. We did
similar analyses with intrapartum and elective caesareans
Crude regression
coeffi cient
Standard
error
p Adjusted regression
coeffi cient*
Standard
error
coeffi cient†
Standard
error

p
Maternal outcome
Severe maternal morbidity and mortality index 0·284 0·0729
0·0002 0·272 0·1184 0·02 0·277 0·1148 0·02
Postnatal treatment with antibiotics 0·455 0·1217 0·0003 0·492
0·2030 0·02 0·496 0·2070 0·02
Perineal laceration or postpartum fi stula 0·092 0·0512 0·08
0·082 0·0828 0·3 0·097 0·0842 0·2
Perinatal outcome
Fetal death 0·107 0·0389 0·007 0·153 0·0652 0·02 0·163
0·0654 0·01
Fetal death‡ 0·147 0·0635 0·02 0·161 0·0640 0·01
Neonatal death 0·096 0·0419 0·02 0·014 0·0704 0·8 0·010
0·0705 0·9
Neonatal death‡ –0·001 0·0595 0·99 0·005 0·0605 0·9
≥7 days on neonatal intensive or special care unit 0·289 0·0762
0·0002 0·170 0·1274 0·2 0·139 0·1233 0·3
≥7 days on neonatal intensive or special care unit‡ 0·153
0·1200 0·2 0·134 0·1182 0·3
Maternal outcome 0·213 0·0552 0·0002 0·055 0·0898 0·5 0·023
0·0873 0·8
*Adjusted for proportion of primiparous women, previous

caesarean delivery, and breech or other non-cephalic fetal
presentation. †Adjusted for same variables as in * plus
complexity index of institution and type of institution.
‡Adjusted for same variables as in previous line plus preterm
delivery.
Table 5: Association between proportion of elective caesarean
deliveries and maternal and perinatal outcomes at institutional
level
Crude regression
coeffi cient
Standard
error
coeffi cient*
Standard
error
coeffi cient†
Standard
error
P
Maternal outcome
<0·0001 0·316 0·0954 0·001 0·321 0·1013 0·002

0·1896 0·005 0·591 0·2026 0·004
Perineal laceration or postpartum fi stula 0·090 0·0439 0·04
0·049 0·0755 0·52 0·063 0·0796 0·4
Perinatal outcome
Fetal death 0·110 0·0330 0·001 0·207 0·0581 0·0006 0·190
0·0623 0·003
Fetal death‡ 0·214 0·0575 0·0003 0·201 0·0617 0·002
Neonatal death 0·126 0·0349 0·0004 0·088 0·0569 0·1 0·070
0·0611 0·3
Neonatal death‡ 0·101 0·0530 0·06 0·089 0·0571 0·1
<0·0001 0·229 0·1097 0·04 0·143 0·1150 0·2
0·1088 0·03 0·157 0·1146 0·2
Preterm delivery (<37 weeks’ gestation) 0·219 0·0462 <0·0001
0·060 0·0743 0·4 –0·009 0·0775 0·9
*Adjusted for proportion of primiparous women, previous
caesarean delivery, gestational hypertension or pre-eclampsia or
eclampsia, referral from other institution for pregnancy
complications or delivery, breech or other non-
cephalic fetal presentation, and epidural during labour.
†Adjusted for same variables as in * plus complexity index of
institution and type of institution. ‡Adjusted for same variables
as in previous line plus preterm delivery.
Table 4: Association between proportion of all caesarean

deliveries and maternal and perinatal outcomes at institutional
level
Articles
as dependent variables. For elective caesarean, only
primiparity and caesarean delivery in previous pregnancy
remained signifi cant, explaining 64% of the variation in
rates; for intrapartum caesarean delivery, previous
caesarean section, induction of labour, institutional
complexity, and private nature of institution were retained
in the fi nal model, explaining 52% of the variance.
What was the association between caesarean delivery
and pregnancy outcomes after adjustment for population
risk and institutional characteristics? We used rate of
caesarean delivery as the independent variable and each
maternal and perinatal outcome, both transformed to the
logit scale, as dependent variables in separate multiple
linear regression analyses. In the crude analysis, an
increase in rate of caesarean delivery was associated with a
signifi cantly higher risk for severe maternal morbidity and
mortality and postnatal treatment with antibiotics (table 4).
When adjusted for the set of confounding variables (case-
mix) and complexity and type of institutions, caesarean
delivery remained highly signifi cantly associated with an
increase in the morbidity and mortality index and in
postnatal treatment with antibiotics (table 4). Rates of third
or fourth degree perineal laceration or postpartum fi stulae,
or both, were not independently associated with rates of
caesarean delivery.

Table 4 also summarises the crude and adjusted
association between rate of caesarean delivery and
perinatal outcomes. In the crude analysis, caesarean
delivery rates were positively and signifi cantly associated
with an increase in the rate of the four negative perinatal
outcomes. After adjustment for the case-mix of the
populations served, the rate of caesarean delivery was
positively and statistically associated with an increase in
the rates of fetal death, numbers of infants admitted to
the neonatal intensive care unit for 7 days or more, and
borderline signifi cant for neonatal death after adjusting
for preterm delivery. Adjustment for type of hospital did
not change these results, although adjustments for
complexity of the institutions eliminated these neonatal
negative eff ects, except for fetal death (table 4).
We stratifi ed the results presented in table 4 by elective
and intrapartum caesarean delivery. The increase in
elective caesareans was positively and signifi cantly
associated with the proportion of women with the severe
morbidity and mortality index and postnatal antibiotic
treatment after adjustment for all confounding variables,
as in table 4 (table 5). Of the perinatal outcomes, only fetal
death was independently associated with elective
caesarean delivery rates. After adjustment for institutional
type and complexity, the maternal morbidity and mortality
index, postnatal treatment with antibiotics, and fetal death
Crude regression
coeffi cient
Standard
error

coeffi cient*
Standard
error
coeffi cient†
Standard
error
p
Maternal outcome
<0·0001 0·350 0·0754 <0·0001 0·355 0·0892 0·0001
0·1510 0·4 0·207 0·1788 0·5
Perineal laceration or postpartum fi stula 0·088 0·0499 0·08 –
0·033 0·0599 0·6 –0·016 0·0696 0·8
Perinatal outcome
Fetal death 0·101 0·0379 0·009 0·078 0·0468 0·09 0·063
0·0554 0·3
Fetal death‡ 0·080 0·0462 0·08 0·068 0·0549 0·2
Neonatal death 0·140 0·0397 0·0006 0·084 0·0439 0·06 0·072
0·0520 0·2
Neonatal death‡ 0·088 0·0411 0·03 0·084 0·0488 0·09

<0·0001 0·379 0·0813 <0·0001 0·321 0·0949 0·001
0·0809 <0·0001 0·328 0·0946 0·0007
Maternal outcome 0·271 0·0513 <0·0001 0·134 0·0564 0·02
0·080 0·0666 0·2
*Adjusted for proportion of previous caesarean delivery,
gestational hypertension or pre-eclampsia, or eclampsia,
induced labour, and epidural during labour. †Adjusted for same
variables as in * plus complexity index of
institution and type of institution. ‡Adjusted for same variables
as in previous line plus preterm delivery.
Table 6: Association between proportion of intrapartum
caesarean deliveries and maternal and perinatal outcomes at
institutional level
10
5
3
1
0·5
1 10 3020 40 50 70 90
A
dj
us

te
d
m
at
er
na
l m
or
ta
lit
y
an
d
m
or
bi
di
ty
in
de
x
(%
, l
og

it
sc
al
e)
Caesarean delivery rate (%, logit scale)
Adjusted maternal mortality
and morbidity index
Postnatal treatment with antibiotics
5
10
25
50
75
1 10 3020 40 50 70 90
A
dj
us
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at
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t w
it
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, l
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Figure 3: Association between rate of caesarean delivery and
maternal morbidity and mortality index and
postnatal treatment with antibiotics
Rates of outcomes adjusted by proportions of: primiparous
women, previous caesarean delivery, gestational
hypertension or pre-eclampsia or eclampsia during current
pregnancy, referral from other institution for
pregnancy complications or delivery, breech or other non-
cephalic fetal presentation, and epidural during labour,
along with complexity index for institution and type of
institution in multiple linear regression analysis. Curves
based on LOWESS smoothing applied to scatterplot of logit of
rates of caesarean delivery versus logit of adjusted
probability of each outcome.
Articles
remained associated with elective caesarean delivery
(table 5), suggesting that the crude eff ect of caesarean
delivery on neonatal death, rate of infants spending 7 days
or more in the neonatal intensive care unit, and preterm
delivery is confounded by the population characteristics
and complexity of the institution.
Table 6 shows a similar analysis as in table 5, but with
intrapartum caesarean delivery as the independent
variable. After adjustment for the same confounding
variables, the rate of intrapartum caesarean delivery was
associated with an increase in the severe maternal
morbidity and mortality index, neonatal death, rate of
infants spending 7 days or more in the neonatal intensive

care unit (even after adjustment for preterm delivery),
and total preterm delivery. After adjustment for both the
type of institution and institutional complexity, the severe
maternal morbidity and mortality index and rate of
infants spending 7 days or more in the neonatal intensive
care unit remained positively and signifi cantly associated
with rate of intrapartum caesarean delivery.
Finally, we assessed whether there was a threshold rate
of caesarean delivery associated with the noted increase in
negative outcomes, as adjusted for the confounding var-
iables considered in table 4. For postnatal maternal treat-
ment with antibiotics and severe maternal morbidity and
mortality index, the increase seemed linear (fi gure 3). Risk
of preterm delivery and neonatal death rose at caesar ean
delivery rates of between 10% and 20% (fi gures 4 and 5).
Discussion
Our fi ndings indicate that increase in rates of caesarean
delivery is associated with increased use of antibiotics
postpartum, greater severe maternal morbidity and
mortality, and higher fetal and neonatal morbidity, even
after adjustment for demographic characteristics, risk
factors, general medical and pregnancy associated
complications, type and complexity of institution, and
proportion of referrals. The high rates of caesarean
delivery and its more frequent indications were similar
across countries with diff erent health systems and
perinatal outcomes.
Our study had limitations, including the possibility of
selection bias. Sources could result from the inability of
three of the original 11 selected countries to participate in a
timely fashion, the refusal of three selected institutions to
participate, and the deterministic selection of the capital

cities in each country. Furthermore, the large number of
health institutions involved limited standardisation of
diagnoses. We therefore concentrated our analyses on a
few unequivocal morbidity and mortality indicators, using
data prospectively abstracted by staff from the same
hospital; we discussed unclear or incomplete records
directly with the attending medical staff . Additionally, our
real-time, web-based data entry system and its internal
consistency procedures facilitated the identifi cation of
incomplete or inconsistent data, which could then be
queried within a few weeks of the event. For logistical
reasons, the survey lasted only 3 months, and so did not
capture possible time-related eff ects—eg, in the
characteristics of the population or relating to training of
new staff . Our analyses and inferences are based on
institutional-level data, for the purpose of making
institutional-level recommendations. The so-called eco-
logical fallacy24 does not, therefore, apply here.
Although we have made extensive statistical adjustments
for many possible confounding variables, unidentifi ed
factors might have aff ected our noted associations. The
consistent trends noted are, however, unlikely to have been
aff ected in such a way. Finally, the very high rates of
caesarean delivery observed in this survey may not be
directly extrapolated to the whole country or region, but
should refl ect very well the situation in large institutions in
5
7·5
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12·5

1 10 3020 40 50 70 90A
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Intrapartum death Neonatal death
intrapartum death (per 1000 births) and
neonatal mortality (per 1000 livebirths)
Mortality rates adjusted by proportions of: primiparous women,
previous caesarean delivery, gestational

institution in multiple linear regression analysis.
1
2
3
4
5
10
1 10 3020 40 50 70 90
A
dj
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ay
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ys
(%
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2·5

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(%
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Stay in neonatal intensive care unit
for ≥7 days
Preterm delivery
neonatal admission to intensive care for 7 days
or more and preterm delivery
Rates of outcomes adjusted by proportions of: primiparous
women, previous caesarean delivery, gestational
institution in multiple linear regression analysis.
Articles
these countries. We also believe that the relationsships
with outcomes we have succeeded in identifying should be

generalisable beyond the participating institutions.
Independent of mothers’ risk, use of epidural in labour,
or type and complexity of institution, high rates of
caesarean delivery were associated at the institutional level
with postnatal treatment with antibiotics, in addition to
the prophylactic antibiotics recommended after caesarean
delivery. These fi ndings concur with the increased level of
infections associated with caesarean delivery in hospitals
in developed countries.25 Caesarean delivery rates were
also independently associated with the maternal morbidity
and mortality index, which included conditions such as
blood transfusions in agreement with reported higher risk
of caesarean delivery for severe postpartum haemorrhage26
and the proportion of women who stayed in hospital for
more than 7 days postpartum—ie, beyond the maximum
stay for uncomplicated caesarean delivery. Also, rates of
caesarean delivery were not associated with a protective
eff ect on perineal lacerations, as could have been
expected.
Caesarean delivery did not improve perinatal outcomes
either, as suggested by data from developed countries.27 On
the contrary, an increase in fetal death was independently
associated with caesarean delivery, especially elective
caesarean delivery. This fi nding is diffi cult to interpret,
since we did not record the precise timing of death vis-à-vis
the indication for caesarean, although elective caesarean
delivery is usually not indicated for stillbirths. However,
similar observations have been made in high-risk women
who had had a previous caesarean (the most common
indication for caesarean delivery in our population)28 and
among obstetricians in the USA with high rates of
caesarean delivery, who also recorded higher rates of fetal
death among low birthweight infants than obstetricians
with lower rates of caesarean deliveries.27

SAAD COLLEGE OF NURSING AND ALLIED HEALTH SC.docx

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