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Introduction. Persistent pain in the operated region is a common complication of many types of surgery. Previous research suggests that at least 5-10% of women experience persistent scar pain following caesarean section (CS), but does not explain why women rarely access health care, how this pain may affect them or what their perceived health care needs are. This study employed a mixed methods approach to establish the impact of caesarean scar problems and any associated healthcare needs, from the perspective of the individual. Permissions for the study were received from the University of Brighton, Research Ethics & Governance Committee, National Information Governance Board and the researcher's NHS Trust. The study was conducted in three sequential phases. Phase 1. Self report. Women rarely visit clinics for persistent post-CS pain, so their perspective was gained initially by investigating informal discussions on publicly accessible internet sites. Findings: Pain in the scar area, but also healing difficulties and scar shape, were a problem for some women. There might be a need for improved information, advice and treatment. Phase 2. Survey. In order to overcome the bias inherent in internet reporting, a postal questionnaire was designed to explore the issues identified in Phase 1 in the local population. The questionnaire was sent out to 630 women, all of whom had undergone CS at the researcher's NHS Trust 6 to 30 months previously. Findings: Scar related issues from phase 1 were confirmed. CS scars clearly affected participants in various ways and some were troubled by them, but it was not clear why few sought professional help. Phase 3. Qualitative interviews. In order to explore the findings in greater depth, 19 respondents from Phase 2 were interviewed. Topics were the impact of the CS scar on the individual, concerns related to the scar and perceived associated healthcare needs. Themes were identified and analysed using a Framework approach. Findings: Most participants had learned to live with any CS scar problems they might have. Their main concerns were related to a potential subsequent pregnancy. However, many felt that information and advice received before and immediately after CS had not met their needs, making recovery from CS and learning to cope with any remaining problems difficult. Conclusion. This study identified problems with effective provision of information to service users. Women feel poorly prepared for potential consequences of CS such as slow recovery, impact on activity, scar shape, and altered body image and confidence. This raises questions over the issue of informed consent and shared decision making.

The study investigated the cost-effectiveness of caesarean section (CS) as the major component of Emergency Obstetric Care (EMOC) in a humanitarian context. Research was conducted from December 2007 until June 2008 in Bunia, in the north-east of the Democratic Republic of Congo. Methods A case-control study explored the factors determining whether a woman had a CS or a vaginal delivery. Cases (n=178) were randomly selected from women who had delivered by CS. Controls (n=180) were women who had delivered vaginally within two weeks of a case and were matched by place of residency. Face-to face interviews in the local language used a structured questionnaire about obstetric and socio-economic factors. Obstetric care was assessed during repeat visits to health structures using checklists. Provider cost of CS was calculated for four hospitals, of which one provided free emergency healthcare. Information about cost allocation to CS was collected from hospital managers, maternity staff, and administrators. Costs were verified with local entrepreneurs, international organisations and UN agencies. The social cost of maternal death was discussed in focus groups, which also obtained user cost information additional to the data from the case-control study. Results CS constituted 9.7% of expected deliveries in the Bunia Health Zone. During the study period, the humanitarian hospital performed 75% of all CS. There were no elective CSs in the study sample. The study found no evidence of obstetric surgery for non-medical reasons. Previous CS and prolonged labour during this delivery were the strongest predictive factors for CS. The risk increased with age of the mother and decreased with the number of children alive. Fifteen obstetric deaths were reported to the research team, three among them were women who had a CS. After adjusting the observed number for missed pregnancy-related and late post-partum deaths, the estimated number of maternal deaths avoided by humanitarian EMOC, compared to expected mortality without additional services, ranged from 20 to 228. Compared to recent estimates for the DRC, perinatal deaths avoided ranged from 237 to 453. Cost-effectiveness was expressed as cost per year of healthy life expectancy (HALE) gained. The estimated cost of adding one year of HALE by providing CSs in a humanitarian context ranged from 3.77 USD to 9.17 USD. Comparison of the cost of EMOC and the social cost of maternal death was complicated by the existence of local customs such as “sororate”. The user capacity to pay for health insurance was found to be low. Conclusion Caesarean sections as part of humanitarian assistance were cost-effective. To keep EMOC accessible during and following the transition from emergency relief to development, a change in the national financing policy for health services is advisable.

Les taux de césarienne sont en constante croissance dans le monde. Ces dernières années, on assiste à une augmentation sans cesse des taux hospitaliers d’accouchement par césarienne dans les pays à faible ressource malgré les recommandations de l’Organisation mondiale de la santé de ne pas dépasser 10 à 15 %. En Afrique au sud du Sahara, en particulier au Sénégal et au Mali, des politiques de subvention de la césarienne ont été introduites à l’échelle nationale à partir de 2005. Ces mesures ont contribué à l’augmentation de l’utilisation des services de maternité et des taux de césarienne. Si l’accessibilité financière à la césarienne a été améliorée substantiellement, la qualité n’a pas toujours suivi. Or, une augmentation trop importante des taux de césarienne peut avoir des effets négatifs sur la santé maternelle et périnatale. Par exemple, l’augmentation des taux institutionnels de césarienne au dessus de 10% en Amérique latine était associée à une augmentation de la mortalité maternelle et périnatale hospitalière. Trois ans après la mise en œuvre des politiques d’exemption des césariennes, le Programme Gesta international (PGI) a été mis en œuvre pour améliorer la qualité des soins obstétricaux dans 23 hôpitaux de référence au Sénégal et au Mali. Ce programme se basait sur l’audit clinque et la formation médicale continue du personnel sur les pratiques optimales en matière de soins intrapartum. Un essai contrôlé randomisé en grappe (essai QUARITE) a été mise en œuvre en 2007-2011 pour tester l’effet du PGI sur la mortalité maternelle hospitalière au Sénégal et au Mali. Initialement prévu pour améliorer la qualité des soins intra-partum, je me suis posé la question de l’efficacité de ce programme sur la pratique et les résultats de la césarienne. Les résultats de notre étude montrent que le PGI a permis de réduire l’évolution des taux de césarienne institutionnels dans les hôpitaux du groupe d’intervention comparativement à l’évolution dans le groupe contrôle. Par ailleurs, nous avons trouvé que le PGI a été plus efficace, en terme de réduction de la mortalité maternelle, parmi les femmes césarisées que parmi celles qui ont accouché par voie vaginale. Nous avons donc recommandé que des programmes d’amélioration de la qualité des soins soient mis en œuvre pour accompagner les politiques de subvention en cours dans la plupart des pays en Afrique au sud du Sahara et limiter ainsi l’utilisation excessive des césariennes dans ces pays. / Cesarean rates are rising steadily worldwide. In recent years, there has been an increasing cesarean rates in low-resource countries despite the World Health Organization recommended to not exceed 10-15%. In Senegal and Mali free cesarean policies were implemented nationally since 2005 and have contributed to increase the access to cesarean section. Access to cesarean deliveries has been improved substantially but quality of care has not always followed. However, excessive increase in cesarean section rates can have negative impacts on maternal and perinatal health. In Latin America, Asia, and Africa, several studies have shown an intrinsic risk of maternal and neonatal mortality associated with cesareans regardless of the initial health status of the mother or fetus. For example, the increase in hospital-based cesarean rates above 10% in Latin America was associated with an increase risk of maternal and perinatal mortality.Three years after the implementation of cesarean sections free policies, The Advances in Labour and Risk Management (ALARM) international program was implemented to improve the quality of obstetric care in 23 referral hospitals in Senegal and Mali. This program was based on maternal death review and staff training on best practices for intrapartum care. A randomized controlled cluster trial (QUARITE trial) was implemented in 2007-2011 to assess the effectiveness of the ALARM international program on in-hospital maternal mortality in Senegal and Mali. Initially planned to improve quality of Emergency Obstetric and Neonatal Care (EmONC), we assumed that this program was also effective on the quality of cesarean delivery.Results showed that the ALARM international program slowed down the trends of hospital-based cesarean rates in the 23 participating centers of the intervention group compared to the changes observed in the control group. Furthermore, we found that the program was more effective on maternal mortality among women who delivered by cesarean section than among women who delivered vaginally. We recommend that quality improvement strategies should support free cesarean policies to limit the excessive use of cesarean delivery.

Clinical Psychology / M.A. (Clinical Psychology)

Clinical Psychology / M.A. (Clinical Psychology)