PLoS ONE plos plosone PLOS ONE 1932-6203 Public Library of Science San Francisco, CA USA 10.1371/journal.pone.0293029 PONE-D-23-05404 Research Article Medicine and health sciencesWomen's healthMaternal healthBirthLabor and delivery Medicine and health sciencesWomen's healthObstetrics and gynecologyBirthLabor and delivery Biology and life sciencesPopulation biologyPopulation metricsDeath rates Biology and life sciencesPhysiologyPhysiological parametersBody weightBirth weight People and placesGeographical locationsAfricaGhana Medicine and health sciencesWomen's healthMaternal healthAntenatal care Medicine and health sciencesHealth careHealth care facilities Medicine and health sciencesWomen's healthMaternal healthPregnancy Medicine and health sciencesWomen's healthObstetrics and gynecologyPregnancy Medicine and health sciencesSurgical and invasive medical proceduresObstetric procedures Fetal outcomes and their correlates following caesarian section in a rural setting in Ghana Fetal outcomes following caesarian section delivery in Ghana https://orcid.org/0000-0003-1630-2110 Sackeya Eugene Conceptualization Data curation Formal analysis Methodology Project administration Validation Writing – original draft Writing – review & editing 1 2 * https://orcid.org/0000-0001-8130-0766 Beru Martin Muonibe Conceptualization Data curation Formal analysis Methodology Project administration Validation Writing – original draft Writing – review & editing 1 3 Angmortey Richard Nomo Conceptualization Data curation Formal analysis Methodology Project administration Validation Writing – original draft Writing – review & editing 1 3 https://orcid.org/0000-0003-2321-387X Opoku Douglas Aninng Conceptualization Data curation Methodology Supervision Validation Writing – original draft Writing – review & editing 4 5 Boamah Victoria Achiaa Data curation Methodology Validation Writing – original draft Writing – review & editing 6 Appiah Francis Data curation Methodology Validation Writing – original draft Writing – review & editing 4 7 Mohammed Aliyu Data curation Methodology Supervision Validation Writing – original draft Writing – review & editing 1 Department of Epidemiology and Biostatistics, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Tatale District Hospital, Tatale, Ghana Tamale Teaching Hospital, Tamale, Ghana Department of Global Health and International Health, School of Public Health, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana Allen Clinic, Family Healthcare Services, Kumasi, Ghana School of Health and Social Care, Swansea University, Swansea, United Kingdom Department of Social Sciences, Berekum College of Education, Berekum, Bono Region, Ghana Dey Sanjoy Kumer Editor Bangabandhu Sheikh Mujib Medical University (BSMMU), BANGLADESH

The authors have declared that no competing interests exist.

 * E-mail: mcsackeya@gmail.com 31 10 2023 2023 18 10 e0293029 23 2 2023 3 10 2023 2023 Sackeya 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. Background

Regular evaluation of caesarean section (CS) is required due to their rising trend and outcomes. Many women recently opt for elective CS, even in resource-constrained settings. Data evaluating the outcomes of CS is however sparse. Hence, this study sought to determine the rate of fetal mortalities and their determinants following CS in the Tatale District Hospital of the Northern Region, Ghana.

 Methods

A retrospective cross-sectional study was employed to analyze the medical records of 275 women who underwent CS from 2019 to 2021. Data were collected from the hospital’s record of CS cases from 2019 to 2021. Descriptive statistics were used to summarize the data and Pearson’s chi-square/Fisher’s exact test was used to examine the relationship between maternal and obstetric characteristics and fetal mortality. At a 95% confidence interval (95% CI), logistic regression was fitted to assess significant variables and reported the results using odds ratio.

 Results

Of 1667 deliveries, 16.5% of the mothers gave birth by CS. A fetal mortality rate of 76.4 per 1000 total births was recorded following CS. Babies born with low Appearance, Pulse, Grimace, Activity and Respiration (APGAR) scores (0–3) at fifth-minute had an increased risk of fetal mortality (AOR  =  523.19, 95%CI: 49.24–5559.37, p  =  <0.001). Having a history of previous CS, cephalopelvic disproportion and delayed labour were the major indications for CS.

 Conclusion

Overall, this study found a high rate of CS based on the World Health Organization‘s recommended CS rate. Interventions such as reducing the waiting time for surgery and early diagnosis of the need for CS, and ensuring the availability of modern equipment to resuscitate infants with low APGAR scores can significantly improve fetal outcomes following CS.

 The authors received no specific funding for this work. Data Availability All relevant data are within the manuscript and its Supporting Information files. Introduction

A life-saving surgical operation known as a caesarean section (CS) is performed when specific difficulties during pregnancy and labour occur [1]. CS has increased worldwide in recent decades, especially in middle- and high-income countries [2] with rate ascendancy from an estimated 7% in 1990 to 21% in 2021, and is expected to rise further in the coming decade[3]. Inequalities in the use of CS, both between and within nations, as well as the expenditures that unneeded CS imposes on financially strapped health systems, are issues up for debate [4]. Worldwide, CS rates in Eastern Asia (63%), Latin America and the Caribbean (54%), Western Asia (50%), Northern Africa (48%), Southern Europe (47%), and Australia and New Zealand (45%) have been predicted to have the highest rates by 2030 [5]. In resource-constrained areas such as sub-Saharan Africa, having access to safe CS is a key strategy for lowering maternal and neonatal mortalities [6]. Africa has the lowest CS rate in the world with only 7.3% of newborns delivered through this method [7]. Egypt (51.8%) and Mauritius (47%) have the highest CS rates in Africa [7].

Caesarean section can effectively prevent maternal and fetal mortality and morbidity when medically necessary [3]. However, there is little proof that caesarean birth is beneficial to women or infants who do not require it [5]. A review of national data from 159 countries indicated that countries with national CS delivery rates of 5% to 10% had the lowest neonatal and maternal mortality rates [1, 8]. However, the benefits of CS delivery reduces when the rates exceed 10% [8]. This indicates that high CS delivery rates might not have additional benefits in terms of reducing mortality. In all regions, the WHO recommends that the CS delivery rate not exceed 15% of all deliveries [3].

A survey in Ghana reported that nearly 18.5% of women who delivered in health facilities 5 years preceding the survey delivered their babies through CS [9]. While it is not expected that CS rates will be the same across all facilities, regional variations in CS rates have been observed in Ghana, with the Greater Accra Region recording the highest rate, with nearly one in four women (23%) undergoing CS. The following rates have also been observed in the Volta (15%), Ashanti (12%), Eastern (12%), Brong-Ahafo (12%), and Central (11%) Regions in Ghana [9]. Between 1998 and 2014, Ghana had differences in the number of CS births, which grew over time [10]. A study also showed that fetal weight of 4kg and above along with referred pregnant women are the leading indications for CS in northern Ghana [11]. The majority of Ghanaian women (87%) had spontaneous vaginal deliveries whiles about 55% of those who had CS for their most recent birth had an elective rather than an emergency procedure [12]. In a study of women giving birth at the University of Cape Coast Teaching Hospital in Ghana, it was discovered that babies born via emergency CS had a considerably greater rate of adverse fetal outcomes [13].

The present study was conducted to determine the prevalence and factors associated with fetal mortality following CS. This study also sought to estimate the prevalence of CS at the Tatale District Hospital. Considering the complex situations of unmet needs and overuse of CS, coupled with unsafe surgical practices and the non-availability of essential medical equipment for CS operations [1], this study provides significant data for designing public health interventions targeted at improving the outcomes of CS births as well as improving maternal and child health in Ghana and beyond.

 Methods Study design and setting

This was a retrospective analytical cross-sectional study that included 275 women who delivered through CS at the Tatale District Hospital, Ghana. The facility provides medical service to the residents of Tatale Sanguli District, parts of the Republic of Togo, and other neighbouring districts in the Northern Region of Ghana. It also serves as the first point of call for all emergency cases from all sub-district health facilities. Due to the inadequate number of trained midwives in the district, community health nurses augment the efforts of the midwives. The hospital has consistently had only one medical officer who attends to surgical cases such as CS.

The Tatale District Hospital is limited in terms of advanced medical equipment. The facility lacks ultrasonographic machines for diagnosing and assessing pregnancy states in addition to the non-availability of a Neonatal Intensive Care Unit (NICU), a monitoring machine for anaesthesia care and resuscitation devices and an inadequate supply of oxygen. This can affect the quality of CS conducted in the facility.

 Variables description Dependent variable

The key outcome variable was fetal mortality. This was defined as the fetus delivered dead following the CS or died shortly after the operation that is before the mother was moved from the theater to the recovery room. The secondary outcome was the rate of CS. This was defined as the proportion of women who delivered through CS divided by the total number of women who delivered in the hospital for the period expressed as a percentage.

 Independent variables

Ten (10) explanatory variables were selected for the study. These were Appearance, Pulse, Grimace, Activity and Respiration (APGAR) score at the fifth minute, gravidity, parity and gestational age. APGAR score was a composite index obtained from the five cardinal measures at the fifth minute after delivery. An APGAR score at the fifth minute of 4 and above were considered to be moderate to high score whiles a fifth-minute score of 0–3 was considered low [14]. Gravidity indicates the number of times a participant has been pregnant prior to the current pregnancy whilst parity explains the number of times a participant has given birth before the current delivery. The gestational age describes the number of weeks a participant carried a pregnancy before delivery. The mother’s haemoglobin (HB) level indicates the HB level of the mother as recorded in the theatre records book, specifically the HB taken during the process of preparing the woman for the CS. Baby weight refers to the initial weight recorded at birth whiles the time between admission and CS refers to the period between the arrival of participants at the health facility and when the CS was done. Also, antenatal care (ANC) visits indicate the number of times a mother attended ANC before delivery. Type of anaesthesia was defined as whether a pregnant woman was given general anaesthesia or spinal anaesthesia prior to CS while type of CS indicates whether the surgery done was a planned one (elective) or emergency. These variables were selected due to their theoretical and practical significance to neonatal/fetal health [15, 16].

 Data sampling, collection, and management

The census technique was used to review medical records of all CS cases documented in the theatre register from 1st January 2019 to 31st December 2021. This period was purposively selected to assess the fetal mortalities following CS of all cases. The reason for selecting this period was the constant availability of medical officers qualified to provide CS service to pregnant women who may need it. The key variables of interest extracted for the study included maternal age, parity, gravida, educational level, haemoglobin level and employment status. The type of CS delivery (emergency or elective CS), type of anaesthesia (general or spinal), the fetal weight at birth and the time between admission and the CS were also retrieved from the theatre register. The data were retrieved using a predesigned checklist (designed using Microsoft Excel software). Only variables with missing values less than ten per cent were considered with missing values manually imputed using either the mean, median or the mode.

Data retrieved from the theatre register were compared with the labour room register and the ANC register to ensure accuracy, consistency and also to track and fill all missing data from the records in the theatre. The data was saved on a computer hard drive and also in a Google drive for use and protection.

 Statistical analysis

STATA statistical software version 16.0 was used to analyze the data. Descriptive statistics using mean, standard deviation, frequencies, and percentages were used to describe categorical and continuous variables. Cross-tabulation computation was done for the outcome variable across the key explanatory variables. At a cut-off p-value of ≤0.05, a chi-square test of independence or Fisher exact test was calculated between the outcome variable and key explanatory variables and those that were not significant were not entered into the multivariate analysis. At a 95% confidence interval (95% CI), two logistic regression models were fitted between the outcome variable and key explanatory variables. The first model (Model I) explored a bivariate association whilst Model II followed a multivariate approach. The results were reported in crude odds ratio (COR) and adjusted odds ratio (AOR) for Model I and Model II respectively. A multi-collinearity test was performed for the key explanatory variables using the Variance Inflation Factor (VIF). The VIF results indicated no evidence of multi-collinearity between the explanatory variables (Mean VIF = 1.06, Maximum VIF = 1.12 Minimum VIF = 1.02) (see S1 Table). Finally, the Hosmer-Lemeshow test was applied to measure the model fit which indicated no evidence of poor fit (P = 0.72).

 Results

A total of 1667 deliveries were recorded at the hospital within the period. The mean age of the mothers was 27.9 (±7.2) years. Out of the 1667 deliveries recorded, 275 (16.50%) were born by CS out of which 21 (7.64%) fetal mortalities were recorded (fetal mortality rate of 76.4 per 1000 total births). Majority (89.1%) of children delivered had APGAR score recordings from 4 to 10 in the fifth minute and about one-tenth (10.9%) recorded 0 to 3 APGAR scores in the fifth minute after delivery. About one-fifth (19.3%) had their CS as a result of cephalopelvic disproportion (CPD) [Table 1].

10.1371/journal.pone.0293029.t001 Study participants’ characteristics and Fetal outcome (N = 275).
Univariate Bivariate
Variable Fetal outcome
n (%) Alive n (%) Died n (%) X2 (p-value)
Age Group 0.876*
15–19 28 (10.2) 27 (96.4) 1 (3.6)
20–34 187 (68.0) 172 (92.0) 15 (8.0)
35–49 83 (21.8) 55 (91.7) 5 (8.3)
Mean age (±SD) 27.9 (±7.2)
NHIS Status 0.382*
Insured with NHIS 269 (97.8) 249 (92.6) 20 (7.4)
Not insured with NHIS 6 (2.2) 5 (83.3) 1 (16.7)
Employment status 0.12 0.726
Employed 187 (68) 172 (92.0) 15 (8.0)
Unemployed 88 (32) 82 (93.2) 6 (6.8)
Occupation (n = 187) 0.781*
Civil servants 4 (2.1) 4 (100) 0 (0.0)
Farmers 110 (58.8) 99 (90.0) 11 (10.0)
Traders 41 (21.9) 39 (95.1) 2 (4.9)
Level of Education 0.941*
No formal education 185 (67.3) 169 (91.4) 16 (8.7)
Primary level 14 (5.1) 14 (100.0) 0 (0.0)
JHS level 29 (10.6) 27 (93.1) 2 (6.9)
SHS level 38 (13.8) 35 (92.1) 3 (7.9)
Tertiary level 9 (3.3) 9 (100.0) 0 (0.0)
Gravidity 0.14 0.708
Primigravida 74 (27.3) 69 (93.2) 5 (6.8)
Multigravida 197 (72.7) 181 (91.9) 16 (8.1)
Parity 0.798*
Primiparous 131 (48.3) 122 (93.1) 9 (6.9)
Multiparous 84 (31.0) 76 (90.9) 8 (7.1)
Grand multiparous 56 (20.7) 52 (92.9) 4 (7.1)
Type of CS 0.618*
Emergency CS 269 (97.8) 248 (92.2) 21 (7.8)
Elective CS 6 (2.2) 6 (100.0) 0 (0)
Type of anaesthesia 0.085*
Spinal anaesthesia 252 (91.6) 235 (93.3) 17 (6.7)
General anaesthesia 23 (8.4) 19 (82.6) 4 (17.4)
Baby APGAR score at 5th minute <0.001*
Low (0–3) 30 (10.9) 10 (33.3) 20 (66.7)
Moderate/high (4–10) 245 (89.1) 244 (99.6) 1 (0.4)
ANC visits 7.27 0.007
Less than 4 visits 38 (13.8) 31 (81.6) 7 (18.4)
4 or more visits 237 (86.2) 223 (94.1) 14 (5.9)
Gestational age 4.75 0.029
Pre-term 75 (27.3) 65 (86.7) 10 (13.3)
Term/ Post-term 200 (72.7) 189 (94.5) 11 (5.5)
Mother’s HB level 0.031*
Below 7.6 17 (6.2) 13 (76.5) 4 (23.5)
7.6 and above 258 (93.8) 241 (93.4) 17 (6.6)
Time b/n admission and CS 0.002*
Within 30 minutes 11 (4.0) 9 (81.8) 2 (18.2)
Within 2 hours 69 (25.1) 58 (84.1) 11 (15.9)
More than 2 hours 195 (70.9) 187 (95.9) 8 (4.1)
Baby’s weight at birth 6.65 0.031
Low weight 55 (20.0) 47 (85.5) 8 (14.5)
Normal weight 220 (80.0) 207 (94.1) 13 (5.9)

SD = standard deviation, NHIS = national health insurance scheme, JHS = junior high school, SHS = senior high school, CS = caesarean section, ANC = antenatal care, b/n = between

* = Analyzed using Fisher’s exact test

From the bivariate analyses, the baby’s APGAR score at the fifth minute was found to be associated with fetal mortality. Other variables that were found to be associated with fetal mortality included the number of ANC visits by mothers, time between admission and CS as well as the baby’s birth weight [Table 1].

Indicators for CS

Of the total number of CS, 19.3% were as a result of cephalopelvic disproportion. Also, 17.5% were due to the mother’s history of previous CS and delayed labour accounted for 15.3% of CS operations. Almost 1 in every 10 fetal mortalities (8.27%) occurred among mothers who presented with antepartum haemorrhage. Meanwhile, postdated pregnancies, mothers with bad obstetric history and multiparity recorded no fetal mortalities [Table 2].

10.1371/journal.pone.0293029.t002 Indications for caesarean section.
Indication for CS Total n (%) Died n (%) Alive n (%)
Antepartum haemorrhage 23 (8.4) 9 (3.3) 14 (5.1)
Bad obstetric history 7 (2.6) 0 (0.0) 7 (2.6)
Cephalopelvic disproportion 53 (19.3) 3 (1.1) 50 (18.2)
Delayed labour 42 (15.3) 2 (0.7) 40 (14.6)
Distress mother/child 25 (9.1) 2 (0.7) 23 (8.4)
Malpresentation 18 (6.6) 1 (0.4) 17 (6.2)
Medical condition 11 (4.0) 1 (0.4) 10 (3.6)
Multiparous 7 (2.6) 0 (0.0) 7 (2.6)
Post date 22 (8.0) 0 (0.0) 22 (8.0)
Twin gestation 8 (2.9) 1 (0.4) 7 (2.6)
Previous CS 48 (17.5) 2 (0.7) 46 (16.7)
Others 11 (4.0) 0 (0.0) 11 (4.0)
Predictors of fetal mortalities

Children who were born preterm, mothers who visited the ANC less than 4 times, participants with HB level of 7.5g/dl, and women who were admitted within 30 minutes before the CS due to delays in reporting to the hospital in time were found to be statistically associated with fetal mortalities at the bivariate level (Model I). After adjusting for other covariates (Model II), children born with fifth minute APGAR score (0–3) had higher odds of fetal mortality compared to those with fifth minute APGAR score of 4–10 (AOR  =  523.19, 95%CI: 49.24–5559.37, p  =  <0.001) [Table 3].

10.1371/journal.pone.0293029.t003 Logistic regression results of predictors of fetal mortalities.
Model I Model II
Variables COR (95%CI) P-Value AOR (95%CI) P-Value
Baby APGAR score
Moderate/high (4–10) Ref
Low (0–3) 487.99 (59.43–4007.32) <0.001) 523.19(49.24–5559.37) <0.001
ANC visits
4 or more visits Ref
Less than 4 visits 3.60 (1.35–9.60) 0.011 2.68 (0.39–18.65) 0.319
Gestational age
Term/Post-term Ref
Pre-term 2.64 (1.07–6.51) 0.035 1.61 (0.29–8.95) 0.586
Mother’s HB(g/dl)
7.6 and above Ref
7.5 and below 4.36 (1.28–14.83) 0.018) 6.28 (0.30–8.94) 0.236
Time b/n admission and CS
More than 2 hours Ref
Within 2 hours 4.43 (1.70–11.55) 0.002 0.95 (0.19–4.86) 0.951
Within 30 minutes 5.19 (0.96–28.07) (0.056) 0.88 (0.05–15.90) 0.929
Baby weight at birth(kg)
Normal weight Ref
Low weight 2.71 (1.06–6.91) 0.037 0.89 (0.14–5.56) 0.901
Number of observations 275
Model Fit Testing (Hosmer-Lemeshow) 2.87(0.72)

95% confidence intervals in brackets, COR = Crude Odd Ratio, AOR = Adjusted Odds Ratio, Ref = Reference category

 Discussion

The remarkable and consistent growth in the prevalence of CS over the past few decades has prompted more inquiry, discussion, and worry among healthcare professionals, governments, legislators, scientists, and clinicians [1, 17].

The rate of CS (16.5%) in the present study is high compared with the 10% to 15.0% recommended by the WHO [1] but similar to the national rate (16.0%) that was reported in the Ghana Demographic Health Survey and an earlier study (16.0%) in 2017 [18]. However, the CS rate observed in the present study is lower than the 26.9% reported in a study in the Cape Coast, Ghana [13]. The high rates of CS above WHO recommendation in this study may be due to the hospital serving as a referral centre for clinics, health centres, and Community-based Health Planning and Services (CHPS) compounds, as well as referrals from neighbouring districts.

There were 76.4 fetal mortalities per 1000 total births following CS within the study period. This rate was found to be relatively higher compared to a study conducted in Ethiopia, which found 55.6 fetal mortalities per 1000 total births following CS [19]. The difference in the mortality rate could be attributed to the differences available in the two facilities including human resources, infrastructure and other health dynamics. The fetal mortality rate in the Tatale District Hospital following CS was also higher when compared with rates among women with combined delivery methods in a study which sort to compare if facility birth reduced maternal and fetal mortality in Brong Ahafo, Ghana [20]. The reason for this variation could be that most of the facilities within the Brong Ahafo have more skilled staff and modern equipment compared to the Tatale District Hospital.

The most common indicators for CS in the district hospital included cephalopelvic disproportion, previous CS, delayed labour and distressed mother/baby. These findings are relatively similar to an earlier study in Ghana which had previous CS, big baby, failure in progress and fetal distress being the most common indicators for CS [13]. Similar to a study conducted in a teaching hospital in Burkina Faso, our study found that women who suffered antepartum haemorrhage recorded the highest fetal mortalities making it the most dangerous indicator requiring early diagnosis and intervention [21]; hence, the need to train midwives, nurses and other practitioners on the early sign of antepartum haemorrhage and its management.

The study revealed that children born with low APGAR scores (0–3) at the 5th minute had higher odds of fetal mortality compared with children with 4 and above APGAR scores in the 5th minute. This finding is similar to a study that sort to find the association between APGAR scores of 7 to 9 and neonatal mortality and morbidity in a population-based cohort study of term infants in Sweden [22]. The APGAR score is an expression of the infant’s physiologic condition at one point in time, which includes subjective components. Numerous factors can influence the Apgar score, including maternal sedation or anaesthesia, congenital malformations, gestational age, trauma, and interobserver variability.[23]. Paying attention to these factors and taking the necessary steps to avoid them can significantly improve APGAR scores and increase infant survival rates.

Strengths and limitations of the study

The findings in the study are interpreted in the light of the following. Because this is a retrospective study, several critical obstetric outcomes and indications may not have been consistently reported, preventing further subanalysis. As an index study to determine the fetal outcomes following CS at the facility level, the findings give considerable evidence for the current situation and serve as the foundation for future research.

This study was conducted in one setting and thus findings cannot be generalized to represent other health facilities in Ghana, and another notable is the relatively small sample size, which reduces the statistical power and the presence of missing data. One other limitation is the large confidence intervals. This means the results with large confidence intervals should be interpreted with caution as it reduces precision.

 Conclusion

The present study recorded high rates of CS (16.5%) and fetal mortality of 76.4 per 1000 total births following CS. The study found a low APGAR score (0–3) at the fifth minute to be significantly associated with fetal mortality. We recommend a refresher training on early signs and effective management of labour for all midwives and other auxiliary staff who augment the labour workforce. We also recommend a multi-sector collaboration to address some of the challenges identified i.e., ANC attendance, low birth weight, early reporting to the hospital and issues relating to maternal haemoglobin levels.

 Supporting information Multi-collinearity test results.

(DOCX)

 <p>(XLSX)</p> </caption> </supplementary-material> </sec> </body> <back> <ack> <p>We are very grateful to all mothers whose records were reviewed for this piece of work. To the staff of the maternity ward, the ANC unit and the theatre, we thank them for their efforts in saving lives and the documentation without which this study would not have been possible. We are also very grateful to the management of the hospital and the District Director of Health Services for their approval and reviews. Lastly, we are grateful to God for the inspiration, guidance and protection throughout the study.</p> </ack> <ref-list> <title>References Betrán AP, Ye J, Moller AB, Zhang J, Gülmezoglu AM, Torloni MR. The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990–2014. Zeeb H, editor. PLOS ONE. 2016 Feb 5;11(2):e0148343. doi: 10.1371/journal.pone.0148343 26849801 Betran AP, Ye J, Moller AB, Souza JP, Zhang J. Trends and projections of caesarean section rates: global and regional estimates. BMJ Glob Health. 2021 Jun 1;6(6):e005671. doi: 10.1136/bmjgh-2021-005671 34130991 World Health Organization. WHO Statement on Caesarean Section Rates [Internet]. 2015. Available from: https://apps.who.int/iris/bitstream/handle/10665/161442/WHO_RHR_15.02_eng.pdf [Accessed January 2023] Ross MG, Jessie M, Amaya K, Matushewski B, Durosier LD, Frasch MG, et al. Correlation of arterial fetal base deficit and lactate changes with severity of variable heart rate decelerations in the near-term ovine fetus. Am J Obstet Gynecol. 2013 Apr;208(4):285.e1–6. doi: 10.1016/j.ajog.2012.10.883 23107611 Limbs & Things. Limbs & Things. 2022. Increasing Rates of Caesarean Section: Implications for Training. Available from: https://limbsandthings.com/global/news/36013/increasing-caesarean-section-rates-and-the-implications-for-training [Accessed January 2023] Yaya S, Bishwajit G, Okonofua F, Uthman O. Under five mortality patterns and associated maternal risk factors in sub-Saharan Africa: A multi-country analysis. PLOS ONE. 2018 Oct 25;13:e0205977. doi: 10.1371/journal.pone.0205977 30359408 Maswime S, Masukume G. Increasing caesarean sections in Africa could save more mothers lives. The Conversation. 2017. Diallo MH, Baldé IS, Diallo AD, Baldé O, Diallo BS, Sylla I, et al. Maternal Complications of Caesarean Section in a Resource-Limited Country: The Case of the Maternity Unit of Kankan Regional Hospital, Guinea. Open J Obstet Gynecol. 2019;09(07):981–90. Seidu AA, Hagan JE, Agbemavi W, Ahinkorah BO, Nartey EB, Budu E, et al. Not just numbers: beyond counting caesarean deliveries to understanding their determinants in Ghana using a population based cross-sectional study. BMC Pregnancy Childbirth. 2020 Feb 18;20(1):114. doi: 10.1186/s12884-020-2792-7 32070303 Aboagye RG, Boah M, Okyere J, Ahinkorah BO, Seidu AA, Ameyaw EK, et al. Mother and newborn skin-to-skin contact in sub-Saharan Africa: prevalence and predictors. BMJ Glob Health. 2022 Mar 1;7(3):e007731. doi: 10.1136/bmjgh-2021-007731 35296462 Apanga PA, Awoonor-Williams JK. Predictors of caesarean section in Northern Ghana: a case-control study. Pan Afr Med J [Internet]. 2018 Sep 1;29(20). Banchani E, Tenkorang EY. Determinants of Low Birth Weight in Ghana: Does Quality of Antenatal Care Matter? Matern Child Health J. 2020 May 1;24(5):668–78. doi: 10.1007/s10995-020-02895-6 32026325 Prah J, Kudom A, Afrifa A, Abdulai M, Sirikyi I, Abu E. Caesarean section in a primary health facility in Ghana: Clinical indications and feto-maternal outcomes. J Public Health Afr. 2017 Dec 1;8. Razaz N, Norman M, Alfvén T, Cnattingius S. Low Apgar score and asphyxia complications at birth and risk of longer-term cardiovascular disease: a nationwide population-based study of term infants. Lancet Reg Health–Eu Madaj B, Smith H, Mathai M, Roos N, van den Broek N. Developing global indicators for quality of maternal and newborn care: a feasibility assessment. Bull World Health Organ. 2017 Jun 1;95(6):445–452I. doi: 10.2471/BLT.16.179531 28603311 Saturno-Hernández PJ, Martínez-Nicolás I, Moreno-Zegbe E, Fernández-Elorriaga M, Poblano-Verástegui O. Indicators for monitoring maternal and neonatal quality care: a systematic review. BMC Pregnancy Childbirth. 2019 Jan 11;19(1):25. doi: 10.1186/s12884-019-2173-2 30634946 Brüggmann D, Löhlein LK, Louwen F, Quarcoo D, Jaque J, Klingelhöfer D, et al. Caesarean Section—A Density-Equalizing Mapping Study to Depict Its Global Research Architecture. Int J Environ Res Public Health. 2015 Nov 17;12(11):14690–708. doi: 10.3390/ijerph121114690 26593932 DHS. Ghana Special Demographic and Health Survey 2017 | GHDx [Internet]. 2017. Available from: https://ghdx.healthdata.org/record/ghana-special-demographic-and-health-survey-2017 [Accessed December 2022] Elias S, Wolde Z, Tantu T, Gunta M, Zewudu D. Determinants of early neonatal outcomes after emergency cesarean delivery at Hawassa University comprehensive specialised hospital, Hawassa, Ethiopia. PLOS ONE. 2022 Mar 24;17(3):e0263837. doi: 10.1371/journal.pone.0263837 35324921 Gabrysch S, Nesbitt RC, Schoeps A, Hurt L, Soremekun S, Edmond K, et al. Does facility birth reduce maternal and perinatal mortality in Brong Ahafo, Ghana? A secondary analysis using data on 119 244 pregnancies from two cluster-randomised controlled trials. Lancet Glob Health. 2019 Aug 1;7(8):e1074–87. Lankoande M, Bonkoungou P, Ouandaogo S, Dayamba M, Ouedraogo A, Veyckmans F, et al. Incidence and outcome of severe ante-partum hemorrhage at the Teaching Hospital Yalgado Ouédraogo in Burkina Faso. BMC Emerg Med. 2017 May 31;17(1):17. Razaz N, Cnattingius S, Joseph KS. Association between Apgar scores of 7 to 9 and neonatal mortality and morbidity: population based cohort study of term infants in Sweden. BMJ. 2019 May 7;365:l1656. doi: 10.1136/bmj.l1656 31064770 American Academy of Pediatrics. The Apgar Score [Internet]. 2022. Available from: https://www.acog.org/en/clinical/clinical-guidance/committee-opinion/articles/2015/10/the-apgar-score [Accessed January 2023]. 10.1371/journal.pone.0293029.r001 Decision Letter 0 Dey Sanjoy Kumer Academic Editor 2023 Sanjoy Kumer Dey 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. Submission Version 0

13 Jun 2023

PONE-D-23-05404Foetal outcomes and their correlates following caesarian section in a rural setting in Ghana

Dear Dr. Sackeya,

Thank you for submitting your manuscript to PLOS ONE. After careful consideration, we feel that it has merit but does not fully meet PLOS ONE’s publication criteria as it currently stands. Therefore, we invite you to submit a revised version of the manuscript that addresses the points raised during the review process.

Please submit your revised manuscript by Jul 28 2023 11:59PM. If you will need more time than this to complete your revisions, please reply to this message or contact the journal office at plosone@plos.org. When you're ready to submit your revision, log on to https://www.editorialmanager.com/pone/ and select the 'Submissions Needing Revision' folder to locate your manuscript file.

Please include the following items when submitting your revised manuscript:

A rebuttal letter that responds to each point raised by the academic editor and reviewer(s). You should upload this letter as a separate file labeled 'Response to Reviewers'.

A marked-up copy of your manuscript that highlights changes made to the original version. You should upload this as a separate file labeled 'Revised Manuscript with Track Changes'.

An unmarked version of your revised paper without tracked changes. You should upload this as a separate file labeled 'Manuscript'.

If you would like to make changes to your financial disclosure, please include your updated statement in your cover letter. Guidelines for resubmitting your figure files are available below the reviewer comments at the end of this letter.

We look forward to receiving your revised manuscript.

Kind regards,

Sanjoy Kumer Dey, M.D

Academic Editor

PLOS ONE

Journal requirements:

When submitting your revision, we need you to address these additional requirements.

1. Please ensure that your manuscript meets PLOS ONE's style requirements, including those for file naming. The PLOS ONE style templates can be found at

https://journals.plos.org/plosone/s/file?id=wjVg/PLOSOne_formatting_sample_main_body.pdf and

https://journals.plos.org/plosone/s/file?id=ba62/PLOSOne_formatting_sample_title_authors_affiliations.pdf

2. Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information.

Reviewers' comments:

Reviewer's Responses to Questions

Comments to the Author

1. Is the manuscript technically sound, and do the data support the conclusions?

The manuscript must describe a technically sound piece of scientific research with data that supports the conclusions. Experiments must have been conducted rigorously, with appropriate controls, replication, and sample sizes. The conclusions must be drawn appropriately based on the data presented.

Reviewer #1: Partly

Reviewer #2: Yes

**********

2. Has the statistical analysis been performed appropriately and rigorously?

Reviewer #1: Yes

Reviewer #2: No

**********

3. Have the authors made all data underlying the findings in their manuscript fully available?

The PLOS Data policy requires authors to make all data underlying the findings described in their manuscript fully available without restriction, with rare exception (please refer to the Data Availability Statement in the manuscript PDF file). The data should be provided as part of the manuscript or its supporting information, or deposited to a public repository. For example, in addition to summary statistics, the data points behind means, medians and variance measures should be available. If there are restrictions on publicly sharing data—e.g. participant privacy or use of data from a third party—those must be specified.

Reviewer #1: Yes

Reviewer #2: Yes

**********

4. Is the manuscript presented in an intelligible fashion and written in standard English?

PLOS ONE does not copyedit accepted manuscripts, so the language in submitted articles must be clear, correct, and unambiguous. Any typographical or grammatical errors should be corrected at revision, so please note any specific errors here.

Reviewer #1: Yes

Reviewer #2: Yes

**********

5. Review Comments to the Author

Please use the space provided to explain your answers to the questions above. You may also include additional comments for the author, including concerns about dual publication, research ethics, or publication ethics. (Please upload your review as an attachment if it exceeds 20,000 characters)

Reviewer #1: This is a well written manuscript which describes the outcomes among 275 c sections at a District Hospital in Ghana.

In general it is well written and contributes some important insights by way of contributing a detailed look at c section outcomes in one facility.

There are a few limitations which should be addressed.

The paper uses a variety of terms and should more precisely define the period of observation so that the results can be compared to national and international stillbirth and neonatal or perinatal mortality rates. I think these should be reported as rates per 1000 births for comparability.

The analysis generally seems sound, but in one instance the interpretation seems inconsistent with the data presented - this is in regards to mortality rates for women who waited more or less than 2 hours. The conclusions made seem logical but do not align with the data shown - possibly due to small sample size or some other underlying dynamic.

Similarly, the conclusions and recommendations seem like they don't necessarily flow from the data presented. I would recommend giving additional thought to what this data, which is limited by its nature as a retrospectively extracted dataset does show - namely that there were high rates of stillbirth and mortality following c-section - which ideally could be better separated? The data do seem to indicate that anemic mothers with less than 4 ANC carrying small and preterm infants are more likely to lose them, at least in this setting. The conclusion that a NICU is needed may follow, if the proportion of infants who are preterm and delivered by CS (~27%) is reflective of the overall prematurity rate, but that is unlikely and not established.

Nonetheless, I think these limitations in the manuscript can be overcome, and it can serve to provide important knowledge about the rates of adverse outcomes at this level of facility.

Reviewer #2: I congratulate the authors on producing this write-up. However, a couple of comments need to be made. They are:

Abstract:

1. What is the definition of a poor APGAR score? What is the cut-off?

2. What does “Perinatal fetal outcomes” mean? Should be specific. Is it death, complications, or both?

3. (AOR:523.19 95% Cl: 49.24-555.37). The stated adjusted OR with its CI is not right. It should be rechecked.

Introduction

1. The introduction is wordy, and authors should consider cutting it down to about a half to two-thirds.

2. There is no statement of the specific objectives, including any pre-specified hypotheses.

Methodology

1. Line 136: “These were APGAR,”. Which minute APGAR was used? It should be specific as APGAR is done at specific times after birth.

2. Lines 142-143: At which point in pregnancy was the Hb picked? Which one was used if the prospective mother had multiple HBs checked?

3. What were the criteria for the inclusion of specific records into the study? This should be well-spelt out.

4. How was the sample size determined? Why did the authors choose those 3 years and not 2 or 4 years?

5. There is nothing about data capture, data management and software used. These should be specified.

6. What was the percentage of missing values and how were they dealt with in data analysis?

7. Line 169: Indicate that 0.05 is the p-value.

Results

1. Line 194, 195 & 197: Is this at 5 minutes or within the first 5 mins? APGAR is done typically at 1 min and 5 mins. The authors should be specific.

2. All p-values written as 0.000 should be converted to <0.001. p-value cannot be 0.

3. Figures I and II should be converted to a table. The information would be simpler as such.

4. Line 288: The OR with CI combination is wrong. They should be corrected as well as the same in the table.

**********

6. PLOS authors have the option to publish the peer review history of their article (what does this mean?). If published, this will include your full peer review and any attached files.

If you choose “no”, your identity will remain anonymous but your review may still be made public.

Do you want your identity to be public for this peer review? For information about this choice, including consent withdrawal, please see our Privacy Policy.

Reviewer #1: No

Reviewer #2: Yes: Samuel Blay Nguah

**********

[NOTE: If reviewer comments were submitted as an attachment file, they will be attached to this email and accessible via the submission site. Please log into your account, locate the manuscript record, and check for the action link "View Attachments". If this link does not appear, there are no attachment files.]

While revising your submission, please upload your figure files to the Preflight Analysis and Conversion Engine (PACE) digital diagnostic tool, https://pacev2.apexcovantage.com/. PACE helps ensure that figures meet PLOS requirements. To use PACE, you must first register as a user. Registration is free. Then, login and navigate to the UPLOAD tab, where you will find detailed instructions on how to use the tool. If you encounter any issues or have any questions when using PACE, please email PLOS at figures@plos.org. Please note that Supporting Information files do not need this step.

Submitted filename: PONE-D-23-05404_reviewercomments.pdf

 10.1371/journal.pone.0293029.r002 Author response to Decision Letter 0 Submission Version 1

18 Jul 2023

Academic Editor’s comments

Comments: Please provide additional details regarding participant consent. In the ethics statement in the Methods and online submission information, please ensure that you have specified (1) whether consent was informed and (2) what type you obtained (for instance, written or verbal, and if verbal, how it was documented and witnessed). If your study included minors, state whether you obtained consent from parents or guardians. If the need for consent was waived by the ethics committee, please include this information.

Response: This has been done as suggested

...Since this was a retrospective study using secondary data, informed consent was not obtained from the participants and this was made clear during the application for the ethical clearance.

Comment: If you are reporting a retrospective study of medical records or archived samples, please ensure that you have discussed whether all data were fully anonymized before you accessed them and/or whether the IRB or ethics committee waived the requirement for informed consent. If patients provided informed written consent to have data from their medical records used in research, please include this information.

Response: Informed consent was not sought in this study because no physical contact with the study participants was made during the course of the data collection and this was made clear during the ethical clearance application process to the Ethics Committee. All the study data were anonymized and this was also explained in the ethics application.

...Since this was a retrospective study using secondary data, informed consent was not obtained from the participants and this was made clear during the application for the ethical clearance.

Reviewer 1

Comment: This is a well written manuscript which describes the outcomes among 275 c sections at a District Hospital in Ghana. In general it is well written and contributes some important insights by way of contributing a detailed look at c section outcomes in one facility.

Response: Thank you

Comment: The paper uses a variety of terms and should more precisely define the period of observation so that the results can be compared to national and international stillbirth and neonatal or perinatal mortality rates. I think these should be reported as rates per 1000 births for comparability.

Response: The period of observation was stated in the data collection section as “The medical records of all caesarian section cases documented in the theatre register from 1st January 2019 to 31st December 2021 were reviewed”. In most rural settings in Ghana, medical officer availability in rural facilities in a big challenge and so the authors considered this period because at the time there had been consistency in the availability of medical officers who have the skills to render the service of CS to clients who may require the service hence the need to evaluate the service during that period. We have also considered converting the mortality rates to per 1000 to make it comparable with national and international rates as recommended

Comment: The analysis generally seems sound, but in one instance the interpretation seems inconsistent with the data presented - this is in regards to mortality rates for women who waited more or less than 2 hours. The conclusions made seem logical but do not align with the data shown - possibly due to small sample size or some other underlying dynamic

Response: This is true as our interpretation of women who waited for more than two hours to be associated with mortality is inconsistent with what was presented in the bivariate table and hence has been corrected. The demand for CS in the setting is mostly that of emergency, women report late to the health facility or are referred from lower facilities but due to transportation and other related problems, they arrive late and so even though surgery is seen to be within 30minutes of arrival, the condition is already bad compared to those who came to the hospital in time and were monitored for some time before the need for a surgical intervention was decided.

...Women who were admitted within 30 minutes before the CS due to delays in reporting to the hospital in time were found to be statistically associated with fetal mortalities at the bivariate level.

Comment: Similarly, the conclusions and recommendations seem like they don't necessarily flow from the data presented. I would recommend giving additional thought to what this data, which is limited by its nature as a retrospectively extracted dataset does show - namely that there were high rates of stillbirth and mortality following c-section - which ideally could be better separated? The data do seem to indicate that anemic mothers with less than 4 ANC carrying small and preterm infants are more likely to lose them, at least in this setting. The conclusion that a NICU is needed may follow, if the proportion of infants who are preterm and delivered by CS (~27%) is reflective of the overall prematurity rate, but that is unlikely and not established.

Response: We agree that some of the recommendations made did not flow from the finding including the need for a sonography department equipped with the necessary equipment and personnel to assist in the early diagnoses of cases for prompt intervention and the establishment of a functional neonatal intensive care unit and hence have been addressed.

...The present study recorded high rates of CS (16.5%) and fetal mortality of 76.4 per 1000 total births following CS. The study found APGAR score below 4 to be significantly associated with fetal mortalities. We recommend a refresher training on early signs and effective management of labor for all midwives and other auxiliary staff who augment the labor work force.

We also recommend a multi-sector collaboration to address some of the challenges identified i.e., ANC attendance, low birth weight, early reporting to hospital and issues relating to maternal hemoglobin levels.

Reviewer 2

Comment: What is the definition of poor APGAR score? What is the cut-off?

Response: What we meant was the category of APGAR score marked 0-3 in the fifth minute. To address this, the word poor has been replace.

...An APGAR score of 4 and above was considered to be moderate to high score whiles a score of 0-3 was considered a poor score

Comment: What does “perinatal fetal outcome” mean? Is it death, complications, or both?

Response: This has been duly changed to fetal mortality. Our focus has been on the mortality and does not include any other complications.

...Hence, this study sought to determine the rate of fetal mortalities and their determinants following CS in the Tatale District Hospital of the Northern Region, Ghana.

Comment: (AOR:523.19 95% Cl: 49.24-555.37). The stated adjusted OR with its CI is not right. It should be rechecked.

Response: this has been rechecked, we acknowledge a missing value, in the table the upper limit confidence interval was misquoted i.e. 555.37 instead of 5559.37 and this has been corrected and the structure rearranged to alien with standard writing formats.

...Babies born with fifth-minute Appearance, Pulse, Grimace, Activity and Respiration (APGAR) scores of (0-3) had an increased risk of fetal mortality (AOR = 523.19, 95%CI: 49.24–5559.37, p = <0.001).

Comment: The introduction is wordy, and authors should consider cutting down to about a half to two-thirds.

Response: This has been done as suggested

Comment: There is no statement of specific objectives, including any pre-specified hypothesis

Response: This has been provided in the introduction as suggested. The objective of the study was…

...To determine the prevalence and factors associated with fetal mortality following CS. This study also sought to estimate the prevalence of CS at the Tatale District Hospital.

Comment: Line 136 “these were APGAR”, which minute APGAR was that? It should be specific as APGAR is done at specific times after birth.

Response: This has been duly rectified as the fifth minute APGAR score was considered in the analysis.

...These were APGAR score at fifth minute, gravidity, parity and gestational age.

Comment: Line 142-143: at what point was the HB picked? Which one was used if the prospective mother had multiple HBs checked?

Response: in preparing the women for the surgical procedure, one of the requirement is to check the HB level and blood grouping, the reason being that there may be the need for transfusion during the surgery and so the last HB that was checked before the women are taken in for the surgical procedure was used and have been corrected as recommended.

...Mother’s hemoglobin (HB) level indicates the HB level of the mother as recorded in the theater records book, specifically the HB taken during the process of preparing the woman for the CS.

Comment: What were the criteria for the inclusion of some specific records into the study?

Response: In view of the retrospective nature, the possibility of missing data was anticipated and so variables with missing data ten percent or less were considered. In the write up, we acknowledge an omission and that has been corrected accordingly.

...Only variables with missing values less than ten percent were considered with missing values manually imputed using either the mean, median or the mode where appropriate.

Comment: How was the sample size determined? Why did the authors choose those 3 years and not 2 or 4 years?

Response: The sample size was determined using the census technique and the study period was purposefully selected due to the availability of medical officers to render the service CS throughout the years. The three years chosen is believed will give a fair estimate of the occurrence of the health event as the average of the three years is what will be calculated. This we have tried to spell out in the current write up.

...The census technique was used to review medical records of all CS cases documented in the theatre register from 1st January, 2019 to 31st December, 2021. This period was purposively selected to assess the fetal mortalities following CS of all cases within the period. The reason for selecting this period was the constant availability of medical officers qualified to provide CS service to pregnant women who may need it.

Comment: There is nothing about data capture, data management and software used. These should be specified.

Response: We acknowledge this and have duly capture that in the current write up.

...The data were retrieved using a predesign checklist (designed using the Microsoft excel software).

...data was then saved in a computer hard-drive and also in a Google drive for use and protection.

Comment: What was the percentage of missing values and how were they dealt with in data analysis?

Response: We strongly acknowledge this also and have duly capture that in the current write up.

...Only variables with missing values less than ten percent were considered with missing values manually imputed using either the mean, median or the mode where appropriate.

Comment: Line 169: Indicate that 0.05 is the p-value.

Response: This has been addressed as recommended.

...At a cut-off p-value of ≤0.05

Comment: Line 194, 195 & 197: Is this at 5 minutes or within the first 5 mins? APGAR is done typically at 1 min and 5 mins. The authors should be specific.

Response: We acknowledge that the APGAR score is taken in the first and fifth minute after birth. Whiles information on both first and fifth minute APGAR scores are available, we used the fifth minute APGAR score for the purpose of this analysis and so the correction have been effected as recommended.

...Majority (89.1%) of children delivered had APGAR score recordings from 4 to 10 in the fifth-minute and about one-tenth (10.9%) recorded 0 to 3 APGAR score in the fifth-minute after delivery.

Comment: All p-values written as 0.000 should be converted to <0.001. P-value cannot be 0.

Response: This has been duly corrected as recommended

Comment: Figures I and II should be converted to a table. The information would be simpler as such.

Response: All two figures have been converted to tables us recommended.

Comment: Line 288: The OR with CI combination is wrong. They should be corrected as well as the same in the table.

Response: Duly corrected

...After adjusting for other covariates (Model II), children born with fifth minute APGAR score (0-3) had higher odds of fetal mortality compared to those with fifth minute APGAR score of 4-10 (AOR = 523.19, 95%CI: 49.24–5559.37, p = <0.001).

Submitted filename: RESPONSES TO REVIEWERS COMMENTS.pdf

 10.1371/journal.pone.0293029.r003 Decision Letter 1 Dey Sanjoy Kumer Academic Editor 2023 Sanjoy Kumer Dey 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. Submission Version 1

4 Oct 2023

Fetal outcomes and their correlates following caesarian section in a rural setting in Ghana

PONE-D-23-05404R1

Dear Dr. Sackeya,

We’re pleased to inform you that your manuscript has been judged scientifically suitable for publication and will be formally accepted for publication once it meets all outstanding technical requirements.

Within one week, you’ll receive an e-mail detailing the required amendments. When these have been addressed, you’ll receive a formal acceptance letter and your manuscript will be scheduled for publication.

An invoice for payment will follow shortly after the formal acceptance. To ensure an efficient process, please log into Editorial Manager at http://www.editorialmanager.com/pone/, click the 'Update My Information' link at the top of the page, and double check that your user information is up-to-date. If you have any billing related questions, please contact our Author Billing department directly at authorbilling@plos.org.

If your institution or institutions have a press office, please notify them about your upcoming paper to help maximize its impact. If they’ll be preparing press materials, please inform our press team as soon as possible -- no later than 48 hours after receiving the formal acceptance. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information, please contact onepress@plos.org.

Kind regards,

Sanjoy Kumer Dey, M.D

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Reviewers' comments:

 10.1371/journal.pone.0293029.r004 Acceptance letter Dey Sanjoy Kumer Academic Editor 2023 Sanjoy Kumer Dey 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.

20 Oct 2023

PONE-D-23-05404R1

Fetal outcomes and their correlates following caesarian section in a rural setting in Ghana

Dear Dr. Sackeya:

I'm pleased to inform you that your manuscript has been deemed suitable for publication in PLOS ONE. Congratulations! Your manuscript is now with our production department.

If your institution or institutions have a press office, please let them know about your upcoming paper now to help maximize its impact. If they'll be preparing press materials, please inform our press team within the next 48 hours. Your manuscript will remain under strict press embargo until 2 pm Eastern Time on the date of publication. For more information please contact onepress@plos.org.

If we can help with anything else, please email us at plosone@plos.org.

Thank you for submitting your work to PLOS ONE and supporting open access.

Kind regards,

PLOS ONE Editorial Office Staff

on behalf of

Dr. Sanjoy Kumer Dey

Academic Editor

PLOS ONE