Comparative Analysis of Maternal Outcomes: Vaginal Delivery vs. Cesarean Section

QUESTION

As a practice in this study, come up with a research question, instrumentation Instruments to be used (Include examples – if possible)​

• Established instrument – give citation information, validity and reliability​
• Creating your own tool – Ways you will establish validity and reliability​
• Procedures for using instruments.
• Data collection. Also identify a gap in knowledge related to this topic

Title of Research: Comparison of Western Intervention and Holistic Care in relation to Postpartum Hemorrhage in Women​

Introduction 

            Ensuring a safe and healthy pregnancy holds a significant importance in the nursing field. Postpartum hemorrhage (PPH) is the most common complication of pregnancy, and it is the leading cause of death during pregnancy globally (Nigussie et al, 2022). Postpartum hemorrhage is identified as severe bleeding after childbirth with a loss of >500 mL vaginally or >1000 mL via caesarean section (Nigussie et al, 2022). Signs and symptoms of PPH include uncontrolled bleeding, decreased blood pressure, increased heart rate, and severe pain in the vaginal or perineal area. PPH is highly capable of causing severe hypotension, blood flow restriction, and hypovolemia shock which potentially increase the risk for maternal death.

Mortality rate and maternal and neonatal health are highly dependent on the prevalence of vaginal delivery and caesarean section. Initially, the procedure of a caesarean section was introduced as a life-saving intervention in pregnant women with delivery complications. However, several studies have shown that caesarean sections have increased worldwide and are becoming an increasingly on-demand procedure (Azam et al, 2014). Women are exhibiting preference for cesarean section with or without vaginal complications and professionals’ willingness to accept such request is increasing as well (Azam et al, 2014). It is significant in the nursing field that the best mode of delivery is chosen for optimal health of mother and infant in all circumstances. Determining the best mode of delivery remains a key factor in maintaining maternal health.

In view of the fact that caesarean section rate is increasing, the author finds it extremely important to research the comparison between caesarean section and vaginal delivery effect on postpartum hemorrhage and maternal outcomes. As a result, three literature reports on maternal delivery methods were critically analyzed in this literature review. The three articles reviewed in this literature review consist of two systematic reviews (meta-analysis) and one non-experimental study.

Research question

            The aim of this literature review is to compare whether maternal bleeding and outcomes are better with vaginal delivery or cesarean section. How does vaginal birth compared with caesarean section affect postpartum hemorrhage and maternal complications in postpartum women?

Literature search 

            Research articles were found through electronic databases such as Cumulative Index to Nursing and Allied Health Literature (CINAHL), PubMed, and The Cochrane Library. Search terms were combined with Boolean operators to broaden and retrieve specific search results. Combinations of keywords used to find primary studies include postpartum hemorrhage OR postpartum bleeding OR pph OR postpartum haemorrhage AND vaginal and cesarean delivery. The search found 306 articles but only 3 articles met the purpose for this review. Articles were selected based on research title relevance, research article level, an initial review of the abstract, and the availability of full text of the article. Only English language articles were included in the review.

Literature analysis

            Several pieces of research acknowledged that promoting mother and baby health remains an important aspect of nursing. Choosing the best mode of delivery remains a contentious issue due to numerous reasons. The articles analyzed in this literature review agree with this statement.

Article one: Planned caesarean section or trial of vaginal delivery? A meta-analysis.

The first article reviewed was a systematic review, a meta-analysis done to compare maternal outcomes associated with planned mode of delivery in low-risk pregnant women. This systematic review gathers data from seven different studies, six nonrandomized and one randomized. The selection of studies was based on cohort studies who plan to give birth by caesarean section or vaginal delivery. Excluded were studies that based data on the actual mode of delivery in pregnant women.

In the randomized study, the results show “no difference in risk of PPH between the two groups (RR 0.77, 95% CI 0.34 – 1.75, P 1⁄4 0.53) (Azam et al, 2014).” There is also no difference in risk of maternal mortality and postnatal depression symptoms between caesarean section and vaginal birth. However, there is a reduced risk of developing urinary incontinence in caesarean section. In the nonrandomized studies, the results indicate that there is an increased risk for PPH and blood transfusion in planned caesarean section, “PPH (RR 1.15, 95% CI 0.40 – 3.31, P 1⁄4 0.79) and blood transfusion (RR 0.91, 95% CI 0.39 – 2.13, P 1⁄4 0.84).” In addition, the article found that “women who had a planned caesarean section were associated with lower morbidity, including avoidance of haemorrhage, postnatal depression and urinary incontinence compared to those with a planned vaginal birth (Azam et al, 2014).” Nevertheless, the results are not significant because there is no evidence to support this claim.

Strength 

This systematic review retrieved studies from five different databases, including only primary resources to maximize comprehension. The article used nonrandomized results which was most effective for the aim of the study. The study objectives and interventions were clearly described, and the statistical analysis was appropriate for the intended objectives. The study also included a large database of participants, 2,730,410 women, from different places like Southern Thailand, Sweden, Norwegian, Denmark, USA and Canada.

Weakness

The article search generated 13, 983 studies but only seven studies were used in the literature review. A limited number of studies included in the literature review impede the scope of statistical significance of findings, which propose that the article’s findings are questionable. In addition, the findings acknowledged within the article are mis-representative as they have been based on planned mode of delivery rather than the actual mode of delivery in pregnant women.

Article two: Magnitude of postpartum hemorrhage and its associated factors in Ethiopia: a systematic review and meta-analysis 

            Postpartum Hemorrhage is the leading cause of death during pregnancy globally, accounting for 44,000 to 86,000 deaths per year (Nigussie et al, 2022). “Ethiopia is one of the countries with the highest maternal mortality rate (MMR) and almost all these deaths were due to direct obstetric complications. PPH is a leading direct cause of maternal morbidity and mortality in all regions of the country (Nigussie et al, 2022).” In this systematic review and meta-analysis, the goal was to determine the pooled magnitude of postpartum hemorrhage and the pooled effect size of factors associated with postpartum hemorrhage among postpartum mothers in Ethiopia. Data were gathered from 21 studies, three were case-control and the rest were cross-sectional. Studies were conducted in different regions of the country: Amhara region, South nation nationally and people (SNNP) region, Oromia region, Addis Ababa, Tigray region, Dire Dawa, Harar, and national-wide. The pooled magnitude of postpartum hemorrhage in Ethiopia was “8.24% [(95% CI 7.07, 9.40), I2=97.8%, P<0.01].” The region with the highest magnitude of post-partum hemorrhage was SNNP with a result of 16.6%, and the lowest report in Addis Ababa with a result of 1.4%. The pooled magnitude of postpartum hemorrhage was “slightly higher in rural areas 9.99% (95% CI 6.53, 13.43), I2 = 91.2%) than in urban areas 7.69% (95% CI 6.41, 8.96), I2 = 98.1%) (Nigussie et al, 2022).” The study also indicates that “age, prolonged antenatal care (ANC) visits, parity and history of postpartum hemorrhage” were significant factors associated with postpartum hemorrhage. The literature review claimed that the findings were in line with other studies conducted in Uganda and Japan.

Strength 

            The systematic review used mostly cross-sectional study design. It allows the writers to compare different variables at the same time. They looked at participants and critically compared the age differences, parity, bleeding history, and the use of prenatal care in relation to postpartum hemorrhage. In addition, the data were collected from 21 studies with a large database of participants, 93,898. The studies were conducted in different regions of Ethiopia to get an accurate view of the country. This eradicates any bias that one region may have over the other. The study was prepared in Microsoft Excel making the data easy and organized to read. The findings were also found to be adjacent to other studies.

Weakness

            Most primary studies in this systematic review used a cross-sectional study design. This study design makes it difficult to determine the cause-and-effect relationships. It also does not follow up with individuals and cannot be used to analyze behavior over time. In addition, the study was done in Ethiopia where there are geographic and sociocultural differences, and maternal health services. Although the result claimed that the magnitude of postpartum hemorrhage in Ethiopia was moderately high, it also emphasis on the fact that it may be due to low utilization of existing maternal health services, poor access, and unavailability of quality obstetric care (Nigussie et al, 2022).”

Article three: Maternal Outcomes Associated with Caesarean versus Vaginal Delivery

            This non-experimental study was conducted in Sanandaj’s hospital in Iran with 5984 deliveries, of which 3423 were vaginal and 2561 were caesarean section. The study’s aim was to evaluate the relationship between the mode of delivery and maternal outcomes. This study was done over one year, from May 2012 to May 2013. Data were collected from a researcher made questionnaire composed of three parts: demographic characteristic, problems associated with current pregnancy, and mode of delivery. Insignificant variables were removed, and only significant variables were kept estimating the independent effect of cesarean section compared with vaginal delivery on maternal outcomes. The study showed that caesarean section delivery rate in Sanandaj was 42.8%, which is higher than the recommendation rate by World Health Organization (WHO) (Zandyakili et al, 2017). In addition, “the results showed that maternal complication rate in Sanandaj were 101.8 in 1000 deliveries”, and “the maternal morbidity by caesarean section was 10.86% vs 8.2% that of vaginal delivery (Zandyakili et al, 2017).” Furthermore, the study showed that there is a relationship between the method of delivery and maternal outcomes such as bleeding rupture of cervix, use of antibiotics and hospitalization in ICU. The author claimed that this result was unexpected and may indicate the importance of care and attention to the mode of delivery.

Strength 

The study is a non-experimental study which allows for numerous variables to be studied. The study objectives and interventions were clearly described in the article. The questionnaire used for the study was given to healthcare professionals for evaluation, and modifications were made based on their recommendation. This helps create questionaries appropriate for the intended objectives. In addition, the large sample size was a strength of the study. The results were clearly reported and comprehensively collected from all the deliveries for one year.

Weakness

A potential limitation of this study is that the findings do not represent the larger population. The study was solely done on Sanandaj’s hospital alone and the results may not apply to others. In addition, the maternal outcomes were considered only after delivery until discharge from the hospital. This may pose inaccuracy to the findings because there may be some unrecorded complications after discharge. In addition, the hospitals used in this study were “training, non-training, and private hospitals” which may vary in different routines of care and procedures (Zandyakili et al, 2017). This could affect the outcomes of delivery which were not investigated in the study.

Discussion 

The aim of this literature review was to evaluate the comparison whether maternal bleeding and outcomes are better with vaginal delivery or cesarean section. The articles reviewed in this paper did not precisely answer this question. There is a research gap regarding studies on which mode of delivery is best. Nonetheless, the studies have one thing in common. They all agree that providing, maintaining, and promoting mothers and babies’ health always holds a significant importance.

Conclusion 

Overall, there is a gap in research on which method of delivery is best and safest in relation to postpartum hemorrhage and maternal complications. In the absence of high-quality evidence, more research is required. If the author of this literature review were to conduct a research study on determining the best method of delivery, it would be done through a quantitative method, specifically a randomized control trial. This method focuses on the general population rather than patients at a higher risk for maternal complications. It eliminates factors that may be missed and records a more accurate result. Other high quality-controlled studies such as cohort studies are needed to investigate the risks and benefits of vaginal versus cesarean section delivery as well. The study also needs to be carried out over extended periods of time and will require combining data from several databases.

Resources

Azam, S., Khanam, A., Tirlapur, S., & Khan, K. (2014). Planned caesarean section or trial of

vaginal delivery? A meta-analysis. Current opinion in obstetrics & gynecology, 26(6), 461-468. https://doi.org/10.1097/GCO.0000000000000114

Nigussie, J., Girma, B., Molla, A., Tamir, T., & Tilahun, R. (2022). Magnitude of postpartum

hemorrhage and its associated factors in Ethiopia: a systematic review and meta-analysis. Reproductive health, 19(1), 63. https://doi.org/10.1186/s12978-022-01360-7

Zandvakili, F., Rezaie, M., Shahoei, R., & Roshani, D. (2017). Maternal Outcomes Associated

with Caesarean versus Vaginal Delivery. Journal of clinical and diagnostic research: JCDR, 11(7), QC01-QC04. https://doi.org/10.7860/JCDR/2017/24891.10239

ANSWER

Comparative Analysis of Maternal Outcomes: Vaginal Delivery vs. Cesarean Section

Introduction

Maternal health and optimal pregnancy outcomes are paramount in nursing care. Postpartum hemorrhage (PPH), a leading cause of maternal mortality, underscores the significance of choosing the appropriate mode of delivery. This essay critically examines the comparative effects of vaginal delivery and cesarean section on postpartum hemorrhage and maternal outcomes, highlighting gaps in current knowledge.

Research Question

How does vaginal birth compare with cesarean section in terms of postpartum hemorrhage and maternal complications, considering various contributing factors?

Literature Search

Research articles were identified through electronic databases including CINAHL, PubMed, and The Cochrane Library. Keywords such as “postpartum hemorrhage,” “vaginal delivery,” and “cesarean section” were used to locate relevant studies.

Literature Analysis

Three articles were critically evaluated to analyze the implications of delivery mode on maternal outcomes:

Article One: Planned Caesarean Section or Trial of Vaginal Delivery? A Meta-Analysis
This systematic review emphasized maternal outcomes in low-risk pregnant women. The study concluded that planned caesarean sections exhibited no significant difference in PPH risk compared to vaginal births (Azam et al., 2014). While caesarean sections reduced morbidity like postnatal depression and urinary incontinence, the findings lacked statistical significance. Strengths included a large participant database from various regions, although limited study inclusion posed a weakness.

Article Two: Magnitude of Postpartum Hemorrhage in Ethiopia: A Systematic Review
This study highlighted Ethiopia’s elevated maternal mortality rate due to direct obstetric complications, including PPH (Nigussie et al., 2022). The meta-analysis showed varying PPH prevalence across regions and identified associated factors like age and antenatal care utilization. While cross-sectional designs enabled broad comparisons, causality remained elusive due to limitations of the study design.

Article Three: Maternal Outcomes Associated with Caesarean versus Vaginal Delivery
This non-experimental study from Iran linked caesarean deliveries with slightly higher maternal morbidity rates compared to vaginal deliveries (Zandvakili et al., 2017). The study indicated a relationship between delivery mode and complications like bleeding and antibiotic use. Although limited to one hospital, the study provided valuable insights into care and delivery mode.

Discussion

While the articles do not definitively answer the research question, they collectively underscore the importance of maternal health. The absence of consensus highlights a knowledge gap in determining the ideal mode of delivery for optimal maternal outcomes.

Conclusion

Given the scarcity of high-quality evidence, further research through methods like randomized controlled trials and cohort studies is essential to identify the safest mode of delivery in relation to postpartum hemorrhage and maternal complications. Maternal health and patient-centered care should remain a cornerstone of nursing practice, driving future research to improve pregnancy outcomes.