Measuring Coverage in MNCH: Validating Women’s Self-
Report of Emergency Cesarean Sections in Ghana and
the Dominican Republic
Özge Tunçalp1*, Cynthia Stanton1, Arachu Castro2, Richard Adanu3, Marilyn Heymann2,
Kwame Adu-Bonsaffoh4, Samantha R. Lattof5, Ann Blanc6, Ana Langer5
1 Johns Hopkins Bloomberg School of Public Health Baltimore, Maryland, United States of America, 2 Harvard Medical School, Harvard University, Boston, Massachusetts,
United States of America, 3 School of Public Health, University of Ghana, Accra, Ghana, 4 Korle Bu Teaching Hospital, University of Ghana, Accra, Ghana, 5 Harvard School
of Public Health, Harvard University, Boston, Massachusetts, United States of America, 6 Population Council, New York, New York, United States of America
Abstract
Background: Cesarean section is the only surgery for which we have nearly global population-based data. However, few
surveys provide additional data related to cesarean sections. Given weaknesses in many health information systems, health
planners in developing countries will likely rely on nationally representative surveys for the foreseeable future. The objective
is to validate self-reported data on the emergency status of cesarean sections among women delivering in teaching
hospitals in the capitals of two contrasting countries: Accra, Ghana and Santo Domingo, Dominican Republic (DR).
Methods and Findings: This study compares hospital-based data, considered the reference standard, against women’s self-
report for two definitions of emergency cesarean section based on the timing of the decision to operate and the timing of
the cesarean section relative to onset of labor. Hospital data were abstracted from individual medical records, and hospital
discharge interviews were conducted with women who had undergone cesarean section in two hospitals. The study
assessed sensitivity, specificity, and positive predictive value of responses to questions regarding emergency versus non-
emergency cesarean section and estimated the percent of emergency cesarean sections that would be obtained from a
survey, given the observed prevalence, sensitivity, and specificity from this study. Hospital data were matched with exit
interviews for 659 women delivered via cesarean section for Ghana and 1,531 for the Dominican Republic. In Ghana and the
Dominican Republic, sensitivity and specificity for emergency cesarean section defined by decision time were 79% and 82%,
and 50% and 80%, respectively. The validity of emergency cesarean defined by operation time showed less favorable results
than decision time in Ghana and slightly more favorable results in the Dominican Republic.
Conclusions: Questions used in this study to identify emergency cesarean section are promising but insufficient to promote
for inclusion in international survey questionnaires. Additional studies which confirm the accuracy of key facility-based
indicators in advance of data collection and which use a longer recall period are warranted.
Citation: Tunçalp Ö, Stanton C, Castro A, Adanu R, Heymann M, et al. (2013) Measuring Coverage in MNCH: Validating Women’s Self-Report of Emergency
Cesarean Sections in Ghana and the Dominican Republic. PLoS ONE 8(5): e60761. doi:10.1371/journal.pone.0060761
Editor: Dr. Lucy Chappell, Kings College London, United Kingdom, in consultation with Carla AbouZahr, independent consultant, health statistics and policy
Received August 10, 2012; Accepted February 26, 2013; Published May 7, 2013
Copyright:  2013 Tunçalp et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits
unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
Funding: This study was funded by the Maternal Health Task Force at EngenderHealth (PSA-007-01 made to Stanton-Hill Research LLC and GMH-012-02 made to
Harvard Medical School), via their funding from The Bill & Melinda Gates Foundation. The funders had no role in study design, data collection and analysis,
decision to publish, or preparation of the manuscript.
Competing Interests: ÖT and CS conducted this work under Stanton-Hill Research LLC, funded by Maternal Health Task Force at EngenderHealth. AC is a
member of the Editorial Board of PLOS Medicine. All of the other authors declare no competing interests associated with the work supporting this manuscript.
Abbreviations: AUC, area under the receiver operating characteristic curve; DHS, Demographic and Health Survey/s; IF, inflation factor; IQR, interquartile range;
MICS, Multiple Indicator Cluster Survey/s; OR, odds ratio.
* E-mail: otuncalp@jhsph.edu
This paper is part of the PLOS Medicine ‘‘Measuring Coverage in like Bangladesh, recent data show the cesarean section rate
MNCH’’ Collection. increased from 3% to 12% between 2001 and 2010 [3]. Some
middle-income Latin American and Asian countries report rates
between 30% and 46%, and the cesarean section rate for upper-
Introduction middle-income countries has surpassed that of high-income
countries (31% and 28% respectively) [2]. Extreme socio-
Cesarean section rates are rising in many low- and middle- economic disparities in access to cesarean section exist within
income countries. For the first time, the World Health Organi- low-income countries as well. Women in the wealthiest households
zation’s (WHO) World Health Statistics 2012 reports a global often have rates above 20%, whereas among the poorest
cesarean section rate (16%) that exceeds the frequently used upper households in many countries, cesarean section rates are less than
recommended limit of 15% [1,2]. Even in a low-income country one percent [4].
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Validating Self-Report of Emergency C-Sections
High and rising national rates indicate cause for concern, but the operation relative to labor may be easier for women to report.
provide no information on why or how these rates are changing or To increase generalizability, large hospitals in two contrasting
whether the increase is associated with any health gains. Likewise, countries were selected for this study: Ghana and the Dominican
very low rates, as seen in much of sub-Saharan Africa, provide no Republic.
assurance that cesarean sections are serving women in greatest need. The second objective of the study is to estimate the percentage
Currently, cesarean section is the only surgery for which we of emergency cesarean sections that would be obtained from a
have nearly global population-based data [2,5], as a result of the population-based survey, given the assessment of sensitivity and
Demographic and Health Surveys (DHS) and UNICEF’s Multiple specificity from this study. The third objective is to identify
Indicator Cluster Surveys (MICS). However, few surveys in low- characteristics of women who accurately report the status of their
income countries have incorporated questions that go beyond delivery by cesarean section.
mode of delivery [6].
Although large-scale surveys provide the majority of global data Contrasting Countries: Ghana Versus the Dominican
on cesarean section, the question on cesarean section has not been Republic
validated. One study assessing the reliability of self-reported In Ghana, maternal mortality is high at 378 per 100,000 births
cesarean section rates in the DHS in six low-income countries in 2007 [11]. Skilled attendance at birth in Ghana has increased
showed that self-reported cesarean section rates were consistently over the past 20 years from 41% to 60% [12], most of which has
higher than hospital-based cesarean section data applied to occurred since 2003 when the Ghana Health Service began fee
population-based births. However, in three quarters of the 31 exemption for delivery services [13]. According to the Ghana
sub-national observations assessed, hospital-based rates fell within DHS survey, the cesarean section rate increased from 4.5% to
95% confidence intervals of the survey-based estimates. The 6.4% between 1990 and 2005, with greater than 10-fold
differences between the two were often less than one percentage differentials in the rate by wealth quintile. As of 2005, the cesarean
point [7]. It is not surprising that reliability of self-reported section rate for 40% of the population was under the WHO
cesarean section is high since women are unlikely to forget or recommended minimum of 5%, and under 1% for the poorest
fabricate having undergone cesarean section. quintile [12]. In contrast, the Dominican Republic is a country with
In response to the need for more in-depth information related to nearly universal coverage of antenatal care and institutional delivery
cesarean section, the Maternal Health Task Force and the Child (.95%) [14], high maternal mortality compared to countries of
Health Epidemiology Reference Group at Johns Hopkins Univer- similar income (179 per 100,000 live births between 2004 and 2008)
sity sponsored a meeting in February 2010 in Baltimore, Maryland [8], and rapidly increasing cesarean section rates. Between 1990
for maternal health researchers and program managers to propose and 2006, the cesarean section rate in the Dominican Republic
an expanded list of indicators related to cesarean section [8]. Their doubled from 22% to 44% [12].
top recommendation and the impetus for this study was the need to
validate an indicator of emergency cesarean section which could be Methods
obtained from surveys of women of reproductive age.
Numerous definitions of emergency cesarean section exist, each The study was conducted in two hospitals. Korle-Bu Hospital is
of which identify a somewhat different group of women. A Medline one of the largest teaching hospitals in Ghana, situated in the
search on emergency cesarean section from 1982 through 2007 by capital, Accra. It is a tertiary referral center with 10,000 annual
Schauberger and Chauhan [9] reported 28 studies which used at deliveries and a cesarean section rate of 30%. In the Dominican
least 12 definitions based on varying criteria including: decision for Republic, the study was conducted at the Maternity Hospital
cesarean section was made in labor, not scheduled, severe Nuestra Señora de la Altagracia, the national referral maternity
maternal/fetal complications (complications were specified in some hospital and a teaching hospital, in the capital, Santo Domingo. It
but not all studies), immediate threat to mother/fetal life, timeliness is a tertiary level hospital with approximately 18,000 deliveries
from decision to incision or delivery, and various combinations of annually and a cesarean section rate of 33% [15]. Both of the
the above-mentioned criteria. In eight studies, no definition was facilities used partographs as routine practice during labor and
provided. In a recent systematic review of cesarean section delivery, although their use might not be consistent at times.
classification systems, Torloni and colleagues [10] identified nine For the first objective, sensitivity, specificity, and positive
classification systems (four based on indications and five based on predictive value of indicators related to caesarean section were
various definitions of ‘‘urgency’’) that do not always use the term calculated from women’s responses to questions in the exit interview
‘‘emergency’’ but are similar in concept; for example: absolute compared against hospital-based data (considered the reference
maternal indication, obligatory, extreme emergency, and crash. In standard). Area under the receiver operating characteristic curve
almost half of these studies, the classification system was designed for (AUC) was estimated for each variable to compare overall validity
use in high-income countries with sophisticated record keeping. for each indicator. Thus, research assistants undertook two data
This study, part of the PLOS Medicine ‘‘Measuring Coverage in collection activities: (1) they abstracted data from the surgical and
MNCH’’ Collection, has three objectives. The first is to validate delivery room registers, individual case notes, and, occasionally,
self-reported data on emergency cesarean section among a sample inquiries to the physician; and (2) they conducted face-to-face
of women who delivered by cesarean section. Two definitions of interviews just prior to hospital discharge of all women who had
emergency cesarean section are tested. Cesarean section by decision undergone cesarean section in each hospital. In Ghana, interviews
time refers to a cesarean section for which the decision to perform were conducted in Twi and English. In the Dominican Republic,
the operation is made after the onset of labor. Cesarean section by interviews were conducted in Spanish and Haitian Creole.
operation time refers to a cesarean section performed after the onset All women undergoing cesarean section were eligible for the
of labor. Both indicators are dichotomous. We test two definitions study. Written informed consent was obtained upon admission to
because (1) in low-income settings, emergency cesarean section the hospital. Data were collected in Accra from June to August
based on decision time may more accurately reflect the chronology 2011, and from August to November 2011 in Santo Domingo.
of events than operation time given inadequate staffing and The following descriptive information was also collected: charac-
resources which often lead to delayed care; and (2) the timing of teristics of the woman and the provider/patient communication
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Validating Self-Report of Emergency C-Sections
she experienced during her hospital stay (from the exit interview), Vecchio [17], sensitivity and specificity estimates from the
and hospital characteristics such as the patient/provider ratio, validation study were used to calculate the prevalence of
volume of births, and deliveries by cesarean section (from hospital emergency cesarean section and other indicators of interest that
administrative data). The formulation of the questions assessed in would be obtained from a population-based survey, using the
this study is summarized in Box 1 (with Spanish version in Text following equation:
S1), along with the two definitions of emergency cesarean section.
The method used for the second objective replicates methods Pr~P|ðSEzSP{1Þzð1{SPÞ,
used by Ronsmans and colleagues when assessing obstetric
complications in Indonesia [16]. Using the equation below from
Box 1. Questions Used in the Exit Interview
GENERAL BACKGROUND QUESTIONS: # During antenatal clinic visits
N # Before the labor pains beganPrevious to this pregnancy, have you ever had a cesarean
section? # After labor pains began
# Don’t know
# If YES, previous to this pregnancy, how many cesarean
deliveries have you had? Operation Time:
N Other than that, have you ever had any surgery/operation N Did you go into labor by yourself/spontaneously?
in your pelvic area?
# Yes
# No
# If YES, what was the surgery/operation?
# Don’t Know
CURRENT DELIVERY: N Did a health care provider give you a medication or drip to
N Were you planning to deliver at Korle-Bu Teaching START your labor?
Hospital/Maternidad Altagracia?
# Yes
# If NO, where were you planning on delivering? # No
N # Don’t KnowWere you transferred from another facility?
N Did you get a cesarean section BEFORE your labor pains
# IF YES, from where? began?
# What was the reason for your transfer?
N What kind of delivery have you had here at Korle-Bu/ # Yes
Maternidad Altagracia? # No
N What was the reason for your operation during your # Don’t Know
delivery? Choose the reason that best applies to your
situation (includes a write-in option for other reasons) EMERGENCY CESAREAN SECTION DEFINITIONS
N When was the decision made for you to have a cesarean/ N Emergency Cesarean Section defined by Decision Time:operation?
N Whose idea was it for you to have a cesarean/operation?
Please select the choice that best describes whose idea it # When was the decision made for you to have a
was (includes a write-in option for other). cesarean?
N Why did you request the cesarean? Answer: After labor pains began
N Who told you that you were having an operation/
2cesarean section? N Emergency Cesarean Section defined by Operation Time:
N Did you go into labor by yourself/spontaneously?
N Did a health care provider give you a medication or drip to # Did you go into labor by yourself/spontaneously?
START your labor?
N Did you get a cesarean section BEFORE your labor pains Answer: Yes
began?
N # Did a health care provider give you a medication or dripHow many weeks were you when you delivered? to START your labor?
N Was the baby born early? Was the baby born on time (at
term)? Answer: Yes/No (depending on the answer to the first
question)
EMERGENCY CESAREAN SECTION QUESTIONS
Decision Time: # Did you get a cesarean section BEFORE your labor pains
began?
N When was the decision made for you to have a cesarean/
operation? Answer: No
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Figure 1. Flowchart of participation in Ghana and the Dominican Republic.
doi:10.1371/journal.pone.0060761.g001
where Pr is the estimate of survey-based prevalence, P is the median number of days between the operation and the interview
hypothetical ‘‘true’’ prevalence in the population, SE is sensitivity, was 3 days (interquartile range [IQR] 2–3). In the Dominican
and SP is specificity. Results regarding the estimated population- Republic, 2,949 women were delivered by cesarean section during
based emergency cesarean section rate were expressed as an the study, of which 52% (1531 women) were interviewed before
inflation factor (IF), that is, as an over- or under-estimation factor hospital discharge and included in the analysis. Twelve women
relative to the ‘‘true’’ rate. This equation is the mathematical refused participation, 92 women interviewed in Haitian Creole
equivalent of the ratio of Test to Actual Positives (TAP ratio) [18], were excluded, and the rest (1,314 women) left the hospital before
which has been utilized in a number of papers in this Collection. they could be interviewed. Factors that limited the Dominican
Of note, two assumptions underlie this calculation: Republic team’s ability to invite the women to participate in the
study included the lack of availability of medical files for review,
1. Self-report of cesarean section is valid. Thus, the sample is the movement of patients within the hospital, and the early
restricted to women who had undergone cesarean. This sample discharge practices of the hospital. The median number of days
is appropriate for a validation study of emergency cesarean between the operation and the interview was one day (IQR 1–2).
section because in a survey questionnaire, only women who
had delivered by cesarean would be asked questions regarding
Characteristics of the Women in Ghana and the
the characteristics of the procedure.
Dominican Republic
2. Results from interviews at hospital discharge are generalizable
Table 1 presents the characteristics of the two study populations
to survey-based responses about events up to three years prior
(as reported in exit interviews), which differ substantially. In
to the survey; that is, we assume that poor recall of an event as
Ghana as compared to the Dominican Republic, mean age and
major as pelvic surgery is low.
parity were higher and education was lower. The population in
Unadjusted logistic regression was used to assess the third objective, Ghana was more rural than in the Dominican Republic, as
with accurate self-report of emergency cesarean section as the dependent expected, and the distribution by religion varied. Proportions of
variable and women’s characteristics as the independent variables. women with previous cesarean sections were similar across the two
Sample size for the study was calculated before the data populations (35% in Ghana and 38% in the Dominican Republic).
collection and was based on an assumption of 80% sensitivity, a Given the large difference in cesarean section rates in the two
Type 1 error at 5% for a two-tailed test, 65% precision and the countries, a lower previous cesarean section rate in Ghana might
true proportion of cesarean sections that are emergency cesarean have been expected. The rate of other pelvic surgery was low in
sections at 30% in Ghana and 5% in Dominican Republic. Based both samples (4.7% in Ghana and 2.7% in the Dominican
on these assumptions, the target sample size was 450 women who Republic).
had been delivered by cesarean section in the Ghanaian site and The data on delivery plan and referral status best illustrate the
1,460 in the Dominican Republic. difference in case mix between the two hospitals. In the
Ethical approval for the study in Ghana was provided by the Dominican Republic, nearly four fifths of women planned on
Institutional Review Board of Korle-Bu Teaching Hospital, delivering at Altagracia Hospital and one quarter of women report
University of Ghana Medical School, College of Health Sciences, being referred to this hospital. In contrast, in Ghana 42% of
Accra, Ghana. The Harvard School of Public Health and the women planned on delivering at Korle Bu Hospital and over three
National Council of Bioethics of the Dominican Republic quarters of women were referred and transferred. Although both
approved the study in the Dominican Republic. hospitals are large urban teaching hospitals, Korle Bu appears to
be used more frequently as a referral hospital than Altagracia,
Results suggesting that complicated deliveries likely represent a higher
percentage of deliveries in Korle Bu than in Altagracia. This may
Study Population partially explain the similar rates of previous cesarean sections in
In Ghana, 740 women were delivered by cesarean section the two hospitals.
during the study period, of which 89% (659 women) were In both populations, 100% of women reported having
interviewed prior to hospital discharge (Figure 1). Of 81 exit undergone a cesarean section. In Ghana, 57% of women reported
interviews that were missed, 64 were women who left the hospital that the decision for delivery via cesarean was made before the
before the interview, 15 did not speak English or Twi, one left the onset of labor (nearly half of which during antenatal care visits);
facility before her discharge, and one refused participation. The 42% reported that the decision was made after the onset of labor.
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Validating Self-Report of Emergency C-Sections
Table 1. Background characteristics of the study population based on women’s exit interviews.
Sociodemographic Characteristics Ghana (N = 659) Dominican Republic (N = 1,531) p-Valuea
Age, years 0.0001
15–19 16 (2.4) 416 (27.2)
20–24 89 (13.5) 501 (32.7)
25–29 176 (26.7) 332 (21.7)
30–34 219 (33.2) 188 (12.3)
35–39 127 (19.3) 76 (4.9)
40–49 32 (4.9) 18 (1.2)
Education 0.0001
None 48 (7.3) 26 (1.7)
Primary 87 (13.2) 402 (26.3)
Secondary 433 (65.7) 861 (56.2)
Tertiary 91 (13.8) 242 (15.8)
Religion 0.0001
Christian 566 (85.9) 1,065 (69.6)
Muslim 92 (13.9) 0 (0.0)
Other 1 (0.2) 22 (1.4)
No religion 0 (0.0) 444 (29.0)
Marital Status 0.692
Married/cohabitation 556 (84.4) 1,290 (84.3)
Single 100 (15.1) 229 (15.0)
Divorced/separated 3 (0.5) 12 (0.7)
Residence 0.0001
Urban 520 (78.9) 1,396 (91.2)
Rural 136 (20.6) 131 (8.6)
Don’t know 3 (0.5) 4 (0.2)
Obstetric history
Number of pregnancies, mean (SD) 2.81 (1.59) 3.01 (1.83) 0.0158
Number of previous deliveries, mean (SD) 2.34 (1.39) 2.12 (1.32) 0.0003
Previous cesarean section 0.167
No 426 (64.6) 942 (61.5)
Yes 233 (35.4) 589 (38.5)
Previous pelvic surgery (other than cesarean section) 0.021
No 628 (95.3) 1,490 (97.3)
Yes 31 (4.7) 41 (2.7)
Current pregnancy
Gestational age at delivery (weeks) 0.001
,35 21 (3.2) 141 (9.2)
35–37 52 (7.9) 262 (17.1)
38–40 130 (19.7) 797 (52.1)
41–43 38 (5.8) 229 (14.9)
Don’t know 418 (63.4) 102 (6.7)
Gestational age in terms 0.001
Preterm 180 (27.3) 263 (17.2)
Term 318 (48.2) 1,230 (80.3)
Post-term 125 (19.1) 13 (0.9)
Don’t know 36 (5.4) 25 (1.6)
Multiple pregnancy 0.24
Single 623 (94.5) 1,465 (95.7)
Multiple 36 (5.5) 66 (4.3)
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Table 1. Cont.
Sociodemographic Characteristics Ghana (N = 659) Dominican Republic (N = 1,531) p-Valuea
Delivery plan 0.001
Home 14 (2.1) 0 (0.0)
Study hospital 280 (42.5) 1,201 (78.5)
Other facility 365 (55.4) 330 (21.5)
Referral status 0.001
No 151 (22.9) 1,139 (74.4)
Yes 508 (77.1) 392 (25.6)
Cesarean-section indicators
Reporting of cesarean section n/a
No 0 (0) 0 (0)
Yes 659 (100) 1,531 (100)
Reporting of time of cesarean section decision 0.001
During antenatal visits 208 (31.6) 751 (49.1)
Before labor 169 (25.6) 165 (10.8)
After onset of labor 276 (41.9) 597 (38.9)
Don’t know 6 (0.9) 18 (1.2)
Reporting of time of cesarean section 0.001
Spontaneous labor 328 (49.8) 1,047 (68.4)
Induced labor 35 (5.3) 5 (0.33)
Cesarean section before labor 278 (42.2) 359 (23.4)
Don’t know 18 (2.7) 120 (7.8)
Communication
Cesarean section decision maker 0.001
The doctor 591 (89.7) 1,510 (98.6)
The woman 35 (5.3) 10 (0.6)
Other 6 (0.9) 0 (0)
Don’t know 27 (4.1) 11 (0.7)
Cesarean section information 0.001
Doctor 571 (86.6) 1,393 (96.8)
Nurse/midwife 46 (7.0) 10 (0.7)
No one 38 (5.8) 33 (2.3)
Other 4 (0.6) 3 (0.2)
aPearson’s Chi-square tests and/or Yates correction for continuity (when necessary) are used for bivariate and categorical variables. T-tests are used for continuous
variables.
doi:10.1371/journal.pone.0060761.t001
In the Dominican Republic, women reported that the decision for Validation of Cesarean Section Indicators
a cesarean section was made before the onset of labor in 60% of Table 2 presents the prevalence, sensitivity, specificity, positive
cases, of which more than four fifths were made during antenatal predictive value, and AUC and IF for emergency cesarean defined
care visits; in 39% of the cases, the decision was made after the by decision time and by operation time relative to the onset of
onset of labor. labor. It should be noted that information on these indicators was
According to women’s report, the onset of labor also varied mainly collected from the patient files in both of our study settings,
across the two populations. Among women in Ghana, half of represented as a percentage within the study population. For ten
women had a spontaneous onset of labor, 5.3% of women had cases in Ghana (1.5%) and 36 cases in the Dominican Republic
their labor induced, and 42% of women underwent cesarean (2.3%), this was supplemented by information requested from the
section before the onset of labor. In the Dominican Republic, two- medical staff.
thirds of women had a spontaneous onset of labor, there were In Ghana, emergency cesarean section defined by decision time
almost no inductions (0.3%), and 23% underwent cesarean section shows sensitivity and specificity of approximately 80% (79% and
prior to the onset of labor. 82%, respectively) and an IF of 1.06. Emergency cesarean section
The majority of the women in both of the study populations defined by decision time in the Dominican Republic had similar
reported that the decision to perform a cesarean section was made specificity (80%), yet lower sensitivity (50%), leading to an IF
by a doctor and that the doctor informed them about this decision. suggesting almost 40% underestimation in a population-based
survey (0.61). Given the higher prevalence of this indicator in
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Table 2. Validation assessment of cesarean section indicators.
% (Within the Study Sensitivity Specificity AUC Point Positive Predictive Population-Based
Ghana (N = 659) Population)* (95% CI) (95% CI) Estimate (95% CI) Value (%) Survey Estimate (%) IF
Previous cesarean section 36.9 95 (91–97) 98 (97–99) 0.96 (0.95–0.98) 97 37 0.98
Emergency cesarean section by decision time 39.8 79 (73–83) 82 (78–85) 0.80 (0.77–0.83) 74 42 1.06
Emergency cesarean section by the operation time 48.8 84 (80–88) 68 (63–73) 0.79 (0.72–0.79) 74 57 1.18
(single question)
Emergency cesarean section by the operation time 49.4 84 (80–88) 70 (65–75) 0.77 (0.74–0.80) 72 57 1.15
(three–question algorithm)
Spontaneous labor 42.2 85 (80–89) 73 (69–78) 0.79 (0.76–0.82) 70 51 1.21
Induced labor 7.2 37 (23–51) 97 (96–98) 0.67 (0.59–0.74) 49 5 0.76
Cesarean section before labor 50.5 70 (65–75) 84 (80–88) 0.77 (0.74–0.80) 82 43 0.86
Dominican Republic (N = 1,531)
Previous cesarean section 38.2 96 (94–98) 97 (96–98) 0.96 (0.96–0.98) 95 38.5 1.01
Emergency cesarean Section by decision time 64.7 50 (47–53) 80 (77–83) 0.65 (0.62–0.67) 82 39 0.61
Emergency cesarean section by the operation time 66.0 83 (80–85) 53 (48–57) 0.67 (0.65–0.70) 79 71 1.07
(single question)
Emergency cesarean section by the operation time 67.0 88 (86–90) 53 (48–57) 0.70 (0.68–0.73) 77 74 1.11
(three question algorithm)
Spontaneous labor 62.0 89 (87–91) 51 (46–55) 0.70 (0.68–0.72) 75 74 1.19
Induced labor 5.0 1.4 (224–27) 99.7 (0.99–1) 0.50 (0.49–0.52) 20 0.3 0.07
Caesarean section before labor 33.0 53 (48–57) 88 (86–90) 0.70 (0.68–0.73) 68 26 0.77
*The percentages used in this column are based on the data collected from the reference standard (patient records).
doi:10.1371/journal.pone.0060761.t002
Validating Self-Report of Emergency C-Sections
Dominican Republic, positive predictive value was higher in attendance at birth, and therefore high population and facility-
Dominican Republic than in Ghana (82% versus 74%). based cesarean section rates, yet one of the highest maternal
Emergency cesarean section by operation time had sensitivity of mortality ratios in Latin America.
84%, specificity of 68%, and IF of 1.18 in Ghana; in the DR, Results from this study support the premise that self-reporting
sensitivity was 83%, specificity 53% and the IF was 1.07. Positive on cesarean section is valid. Although 100% of women reported
predictive value varied between 72% and 79% for both of the that they had undergone a cesarean section, and self-report on
settings, slightly higher in the Dominican Republic. For explor- previous cesarean section showed excellent results in both
atory purposes, the definition of operation time was refined by populations, validation for both of these questions would require
using the responses to two additional survey questions, which first that the question also be asked of women delivering vaginally.
specified that the woman did experience labor. Thus, women with Nonetheless, these results, coupled with the high sensitivity and
emergency cesarean section were defined as: (1) those who specificity for cesarean section indicator observed in the study
reported a spontaneous onset of labor and that their cesarean from China in this Collection [19], increase our confidence in the
section did not occur before the onset of labor, and (2) those who widely available survey data on self-reported cesarean section.
reported that their labor did not begin spontaneously, that the Results from Ghana for validity and the IF for emergency
health care provider gave them some medication to start labor, and cesarean section defined by decision time are promising. The poor
that their cesarean section did not occur before the onset of labor. In sensitivity results for this indicator in the Dominican Republic
both countries, results for this more refined definition show slight compelled us to consider explanations with our local collaborators.
improvements to validity, and small but opposing changes to the IF. On further exploration, it was discovered that this discrepancy was
In Ghana, the IF improved from 1.18 to 1.15 and, in the Dominican probably due to poor documentation of decisions during antenatal
Republic, the IF increased from 1.07 to 1.11. The validity of the care and the practice in the delivery ward of not checking the
individual question on labor induction showed very low sensitivity antenatal clinical history even though most of the women who
and high specificity in both countries. Sensitivity of reporting on delivered at the facility also attended the antenatal clinic there.
spontaneous onset of labor was 84% and 89% in Ghana and the This suggests that it is likely that women’s reports are more
Dominican Republic, respectively. Specificity was 70% in Ghana accurate than medical records for this specific question. Validity of
and 51% in the Dominican Republic. responses for emergency cesarean section defined by operation
Overall validity assessed by AUC estimates show that in Ghana time in Ghana was less favorable than by decision time. In the
the indicator on emergency cesarean section by decision time had Dominican Republic, the IF for the definition based on operation
the highest validity (0.80), followed by emergency cesarean section time was better than that for decision time, though with a
by the operation time (0.79). The indicators tested in the Dominican specificity of less than 60%. The three-question approach did not
Republic had moderate validity, ranging between 0.65 and 0.70, improve results in either country; therefore our results do not
with the exception of induction of labor, which was very low (0.50). justify the more demanding data requirements for the three-
question definition relative to the one question approach. The
Exploring Accurate Reporting of Emergency Cesarean validation results for the individual question on induced labor, of
Section Status interest to maternal health planners independent of their role in
Unadjusted odds ratios (ORs) showing the association between identifying emergency cesarean section, cannot be recommended
accurate reporting of emergency cesarean and women’s age, based on these results. However, it could possibly be improved via
education, and gravidity are presented in Table 3. In Ghana, experimentation with different formulations of the questions.
women who were referred were half as likely to report accurately It is important to note that the IF in our analyses was used as a
on the emergency status of their cesarean section (defined by measure of indicator quality and not as an adjustment factor for
decision time) as compared to non-referrals (OR: 0.49, 95% CI population-based survey results. Furthermore, there were no
0.29–0.83, p = 0.009). Although there was a positive trend between strong or consistent associations between women’s characteristics
emergency cesarean section (defined by decision time) and age and and accurate reporting on emergency cesarean section that could
education, neither association was statistically significant. None of be used to adjust survey-based results.
the associations with emergency cesarean section defined by The study has a number of limitations. First, the quality of the
operation time were statistically significant. In contrast, in the validation reference standard was not consistently high due to
Dominican Republic there was a negative and statistically different registry systems at the hospitals, as can be observed in the
significant relationship between accurate reporting of emergency Dominican Republic results. Second, this validation study does not
cesarean section defined by decision time and gravidity and age fully replicate the conditions in the DHS and MICS surveys, because
and between emergency cesarean section defined by operation our recall period was a few days, compared to up to five years in
time and age. some surveys. However, given that emergency cesarean section is a
surgical intervention, we hypothesize that women are likely to
Discussion remember the event and crucial circumstances surrounding it [20].
Third, even though we conducted the study in two contrasting
Given the demand for more in-depth information on cesarean countries, both study hospitals were tertiary care facilities in urban
section, this study validated women’s self-report of emergency areas serving populations with greater access to care than in rural
cesarean section using two definitions in two countries. Diverse areas. Also, it should be noted that among the women who had
populations were sought to increase generalizability and to identify cesarean sections in the Dominican Republic study, only 52% were
survey questions, which could be recommended for use in surveys included in the final analysis due to women who left the hospital
in large-scale survey programs. Although both of the study sites before they could be interviewed. Given that the median duration of
were referral facilities in capital cities, Ghana represents settings hospital stay across the entire Dominican Republic sample was one
similar to others in much of sub-Saharan Africa and elsewhere day, it is unlikely that this loss to follow-up biased the sample toward
with low skilled attendance at birth, very low population-based women with less complicated pregnancies.
cesarean section rates, and high maternal mortality. In contrast, Population-based cesarean section rates are essential but
the Dominican Republic is a country with nearly universal skilled insufficient information for health care planners, particularly in
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Validating Self-Report of Emergency C-Sections
Table 3. Unadjusted odds of accurately reporting emergency cesarean section using two definitions in the Ghana and Dominican
Republic samples.
Operation Time for Cesarean Section
Decision Time for Cesarean Section (Single Question)
95% Confidence 95% Confidence
Odds Ratio Interval p-Value.|z| Odds Ratio Interval p-Value.|z|
Ghana (N = 659)
Age
#24 1.00 1.00
25–34 1.29 0.77–2.16 0.33 0.85 0.51–1.43 0.55
$35 1.81 0.97–3.39 0.06 1.01 0.56–1.83 0.97
Education
None 1.00 1.00
Primary 1.69 0.73–3.91 0.22 1.00 0.43–2.31 0.98
Secondary 1.65 0.88–3.09 0.12 0.94 0.49–1.83 0.87
University 2.14 0.95–4.83 0.07 0.92 0.42–2.02 0.84
Gravidity
1st 1.00 1.00
2nd 1.01 0.63–1.64 0.96 1.02 0.65–1.60 0.93
3rd 1.11 0.64–1.95 0.71 0.82 0.49–1.36 0.44
4th 1.12 0.48–2.95 0.69 1.71 0.67–4.34 0.26
Referral
No 1.00 1.00
Yes 0.49 0.29–0.83 0.01 1.39 0.92–2.10 0.115
Dominican Republic (N = 1,531)
Age
#24 1.00 1.00
25–34 0.77 0.62–0.96 0.02 0.75 0.58–0.95 0.019
$35 0.65 0.43–1.00 0.05 0.61 0.39–0.96 0.034
Education
None 1.00 1.00
Primary 1.03 0.45–2.35 0.95 0.64 0.23–1.76 0.38
Secondary 1.36 0.60–3.07 0.46 0.79 0.29–2.14 0.64
University 1.78 0.76–4.15 0.18 0.71 0.25–1.98 0.51
Gravidity
1st 1.00 1.00
2nd 0.42 0.32–0.55 0.00 0.90 0.66–1.22 0.49
3rd 0.40 0.31–0.53 0.00 0.78 0.58–1.03 0.08
4th 0.34 0.24–0.51 0.00 0.70 0.46–1.06 0.09
Referral
No 1.00 1.00
Yes 0.91 0.72–1.15 0.41 0.94 0.73–1.23 0.67
doi:10.1371/journal.pone.0060761.t003
countries without adequate routine health information systems to Although low-income countries should strive to establish robust
provide in-depth health facility-based cesarean-related data. The routine health information systems which permit national-level
inadequacy of the cesarean section rate alone (without the monitoring, given current challenges, health care planners will
proportion of emergency operations) is particularly acute in need to rely on national surveys for the foreseeable future. Given
countries where the rate falls between 5% and 10%. In these our reliance on survey-based indicators, the most important aspect
settings, as the cesarean section rate increases, the poorest women of data quality will vary by the purpose and use of the indicator.
may still not have access to life-saving delivery by cesarean section. Although highly valid data are preferred for all purposes, highly
However, the emergency cesarean section trends should be sensitive and specific data are required for individual level
interpreted cautiously in settings such as Brazil, where cesarean analyses, whereas an IF near equality is sufficient for monitoring
sections are almost universal among certain sub-populations. [21] trends.
PLOS ONE | www.plosone.org 9 May 2013 | Volume 8 | Issue 5 | e60761
Validating Self-Report of Emergency C-Sections
The results presented here are promising but insufficient to Acknowledgments
promote inclusion of the questions supporting the two definitions
of emergency cesarean section into international survey program The authors wish to acknowledge Rod Knight of Principia International
for his contribution to the calculation of the sample size, Isaac Newton
questionnaires. Further research on this indicator is warranted.
Hotorvi, Alfred Aikins, and Godwin Binlinla of Korle-Bu Teaching
Such studies should (1) confirm the accuracy of facility-based data
Hospital for their assistance in the data collection and management in
on time of decision to operate in advance of data collection, (2) Ghana, and Ilonka Agramonte, Arismendy Benı́tez, Jean-René Louis,
extend the recall period to be comparable to that of population- Merary Mota, and Angel Peguero for their assistance in the data collection
based surveys, and (3) based on results from the Mozambique in the Dominican Republic.
validation study in this collection [22], allow for 50% loss to
follow-up in sample size estimation to account for the extended Author Contributions
recall period. Furthermore, qualitative research could lead to
Conceived and designed the experiments: OT CS RA KAB AC MH AB
refined formulation of certain questions such as induction of labor,
AL SL. Performed the experiments: OT AC MH KAB RA. Analyzed the
and potentially improve the validity of these additional indicators.
data: OT CS. Wrote the paper: OT CS. Contributed to the interpretation
of data from the DR for the manuscript: AC MH. Provided input to the
Supporting Information manuscript: AC MH KAB RA AB AL.
Text S1 Exit interview in Spanish.
(DOC)
References
1. World Health Organization (2012) World Health Statistics. Geneva, Switzer- 13. Witter S, Arhinful DK, Kusi A, Zakariah-Akoto S (2007) The experience of
land: World Health Organization (WHO). Ghana in implementing a user fee exemption policy to provide free delivery
2. Betran AP, Merialdi M, Lauer JA, Bing-Shun W, Thomas J, et al. (2007) Rates care. Reprod Health Matters 15: 61–71.
of caesarean section: analysis of global, regional and national estimates. Paediatr 14. Castro A (2010) Prevention of Mother-to-Child Transmission of HIV and
Perinat Epidemiol 21: 98–113. Syphilis in Latin America and the Caribbean. In: Castro A, editor. Challenges
3. ICDDRB NM-E (2011) Bangladesh, Maternal Mortality and Health Care Posed by the HIV Epidemic in Latin America and the Caribbean 2009.
Survey 2010; Preliminary Results. Chapel Hill, North Carolina USA: University Washington, DC: Pan American Health Organization, UNICEF, and UNAIDS.
of North Carolina. 15. Dirección General de Información y Estadı́stica de Salud (2008) Salud
4. Ronsmans C, Holtz S, Stanton C (2006) Socioeconomic differentials in Reproductiva por Regiones, Provincias, y Establecimientos de Salud. Santo
caesarean rates in developing countries: a retrospective analysis. Lancet 368: Domingo: SESPAS.
1516–1523. 16. Ronsmans C, Achadi E, Cohen S, Zazri A (1997) Women’s recall of obstetric
5. Debas HT, Gosselin R, McCord C, Thind A (2006) Surgery. In: D.B. Jamison J, complications in south Kalimantan, Indonesia. Stud Fam Plann 28: 203–214.
17. Vecchio TJ (1966) Predictive value of a single diagnostic test in unselected
Measham A, Alleyne G, Claeson M, Evans D et al., editors. Disease Control
populations. N Engl J Med 274: 1171–1173.
Priorities in Developing Countries, 2nd ed: Oxford University Press and The
18. Campbell H, Biloglav Z, Rudan I (2008) Reducing bias from test misclassifi-
World Bank. 1245–1259.
cation in burden of disease studies: use of test to actual positive ratio–new test
6. Holtz S (2007) Clustering of Cesarean Deliveries in Developing Countries.
parameter. Croat Med J 49: 402–414.
Baltimore, MD: Johns Hopkins University.
19. Guo Y, Liu L, Li M, Yang L, Ju L, et al. (2013) Measuring coverage in MNCH:
7. Stanton CK, Dubourg D, De Brouwere V, Pujades M, Ronsmans C (2005)
A validation study linking population survey derived coverage to maternal,
Reliability of data on caesarean sections in developing countries. Bull World newborn, and child health care records in rural China. PLoS ONE 8: e60762.
Health Organ 83: 449–455. doi:10.1371/journal.pone.0060762.
8. CHERG MA #13 (2010) Expanding the List of Indicators regarding Cesarean 20. Coulter A, McPherson K, Elliott S, Whiting B (1985) Accuracy of recall of
Birth: Report from the meeting at The Johns Hopkins Bloomberg School of surgical histories: a comparison of postal survey data and general practice
Public Health. Baltimore, MD. records. Community Med 7: 186–189.
9. Schauberger CW, Chauhan SP (2009) Emergency cesarean section and the 30- 21. Barros AJ, Santos IS, Matijasevich A, Domingues MR, Silveira M, et al. (2011)
minute rule: definitions. Am J Perinatol 26: 221–226. Patterns of deliveries in a Brazilian birth cohort: almost universal cesarean
10. Torloni MR, Betran AP, Souza JP, Widmer M, Allen T, et al. (2011) sections for the better-off. Rev Saude Publica 45: 635–643.
Classifications for cesarean section: a systematic review. PLoS One 6: e14566. 22. Stanton CK, Rawlins B, Drake M, Anjos M, Cantor D, et al. (2013) Measuring
11. Macro International, Ghana Statistical Service, Services. GH (2009) Ghana coverage in MNCH: Testing the validity of women’s self-report of key maternal
Maternal Health Survey 2007. Accra, Ghana and Calverton, Maryland USA. and newborn health interventions during the peripartum period in Mozam-
12. Macro International (2011) Measure-DHS StatCompiler. bique. PLoS ONE 8: e60694. doi:10.1371/journal.pone.0060694.
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