title: Morbidity and mortality following high order caesarean section in a developing country.
abstract: OBJECTIVE
  To determine the morbidity and mortality associated with multiple (four and higher order) caesarean section.
  
  
  METHODS
  A group of 92 women who had undergone four or more caesarean sections was compared with another group of 184 women who had three or less such procedures at the obstetric unit of the University of Nigeria Teaching Hospital, Enugu, Nigeria, between January 1, 1999 and December 31, 2007. The record were retrieved by trained staff and data was extracted using pre-tested forms. SPSS 15 and Z test were used for statistical analysis.
  
  
  RESULTS
  There were a total of 1,755 caesarean sections out of which 92 (5.24%) were higher order repeat caesarean. Three women had the 6th caesarean section, while one had her seventh. Women in the study group were three times more likely to have primary postpartum haemorrhage (p = 0.001); to spend more time on the operation table; and to receive blood transfusion (p = 0.001) compared to the control group. More neonatal morbidities were observed among the controls. Hypertensive disorder was the second most common indication for caesarean section in the control group. There was no clear difference in terms of hospital stay, pre-operative haemoglobin concentration, and caesarean hysterectomy in the two groups. No death was observed during the period.
  
  
  CONCLUSIONS
  Higher order caesarean section was associated with increased maternal morbidity but there was no mortality. Every effort to reduce primary and repeat caesarean sections should be encouraged, as this will reduce the higher order caesarean section rate, especially in the developing world which places high premium on child-bearing and large family size. Counselling on different methods of contraception during visits to antenatal clinics must be done to limit family size.
authors.affiliation: Reproductive Health Unit, Department Obstetrics Gynaecology, University of Nigeria Teaching Hospital, Enugu, Nigeria. hyginus.ezegwui@unn.edu.ng
authors.forename: Ezegwui
authors.initials: E
authors.lastname: Hyginus
authors.forename: Nwogu-Ikojo
authors.initials: NI
authors.lastname: Eric
authors.forename: Ikeako
authors.initials: I
authors.lastname: Lawrence
authors.forename: Nweze
authors.initials: N
authors.lastname: Sylvester
mesh_terms: D000328:Adult; D001803:Blood Transfusion / Q000706:statistics & numerical data; D002585:Cesarean Section / Q000009:adverse effects / Q000379:methods* / Q000401:mortality*; D016009:Chi-Square Distribution; D003906:Developing Countries; D005260:Female; D006801:Humans; D007231:Infant, Newborn; D008428:Maternal Mortality; D009549:Nigeria / Q000453:epidemiology; D010298:Parity; D006473:Postpartum Hemorrhage / Q000453:epidemiology; D011247:Pregnancy; D011256:Pregnancy Outcome; D012189:Retrospective Studies; D012307:Risk Factors