Cesarean section in Ethiopia: prevalence and sociodemographic characteristics

<p><b>Objective:</b> The objective of this study was to assess the prevalence and sociodemographic characteristics of cesarean section in Ethiopia.</p> <p><b>Methods:</b> We used data collected for Ethiopia Demographic and Health Surveys (DHS) conducted in 2000, 2005, 2011, and 2016. A two-stage, stratified, clustered random sampling design was used to gather information from women who gave birth within the 5-year period before each of the surveys. We analyzed the data to identify sociodemographic characteristics associated with cesarean section using log-Poisson regression models.</p> <p><b>Results:</b> The national cesarean section rate increased from 0.7% in 2000 to 1.9% in 2016, with increases across seven of the eleven administrative regions of Ethiopia. Addis Ababa had the highest cesarean section rate (21.4%) in 2016 and the greatest increase since 2000. In the adjusted analysis, women who gave birth in private health facility had a 78.0% higher risk of cesarean section (adjusted prevalence ratio (aPR) (95% CI) 1.78 (1.22, 2.58)) compared with women who gave birth in public health facility. Having four or more births was associated with a lower risk of cesarean section compared with first births (aPR (95% CI) 0.36 (0.16, 0.79)).</p> <p><b>Conclusions:</b> The Ethiopian national cesarean section rate is about 2%, but the rate varies widely among administrative regions, suggesting unequal access. Cesarean sections were highest among urban mothers, first births, births to women with higher education, and births to women from the richest quintile of household wealth.</p

Target gene prediction of miRNAs identified in EVT-derived exosomes.

<p>(A) Gene target identification using CyTargetLinker was performed on the top 20 miRNAs in exosomes from EVT cultured at 8% or 1% oxygen. The genes were identified to be regulated by at least two of our candidate miRNAs, and are detected within at least two miRNA-gene target databases. (B) Top: Gene Ontology analysis using BiNGO was performed on all genes and displayed as a network. Bottom: Gene ontology pathway extracted from exosomes obtained from EVT at 8% and 1% oxygen showing the “migration” and “inflanmmatory response” gene ontology term, respectivetly.</p

Exosomes present in maternal circulation before 18 weeks are positive for HLA-G.

<p>Exosomes were isolated from maternal plasma before 18 weeks of gestation by differential and buoyant density centrifugation. (A) Representative exosomes size distribution isolated from maternal plasma using a NanoSight NS500 instrument. (B) Western blot for HLA-G. (C) Quantification from B.</p

Effect of exosomes on endothelial cell migration.

<p>Endothelial cells (EC) were grown to confluence in complete media, wounds were made using 96 well WoundMaker and culture in absence or presence of exosomes (100 μg protein/ml equivalent to 5 x 10⁸ vesicles per ml) obtained from EVT cultured under 8% or 1% O₂. (A) a, EC image immediately after wounding; b, Graphical representation showing the calculation of initial wound width; c, Graphical representation of cell migration at the midpoint of the experiment. (B) The time course of the effect of exosomes on EC. (C) Area under curves from data in B. Data represents n = 12 well for each point (6 different experiment in duplicate) Values are mean ± SEM. ^†p<0.05 versus all values.</p

Comparison analysis of miRNA profile between exosomes from EVT and present in maternal circulation at early gestation.

<p>(A) Venn diagrams showing unique and common miRNA detected in different exosomes preparations. (B) Highly abundant miRNAs identified in exosomes isolated from EVT cultured under 8% (EXO-8%O₂) or 1% (EXO-1%O₂) oxygen and exosomes isolated maternal circulation obtained from women with normal (EXO-NP), Preeclamptic (EXO-PE) or spontaneous preterm birth (EXO-SPTB). Hierarchical clustering of deep sequencing data was performed across exosomal miRNA samples. Normalisation of the reads was performed by DESeq2 using factors derived from the media ratio method.</p

Clinical characteristics of patients.

<p>Clinical characteristics of patients.</p

miRNA profile in EVT-derived exosomes under low oxygen tension.

<p>(A) The Venn diagram depicts the distribution of common and unique miRNA identified in exosomes released from EVT exposed to 1% and 8% oxygen. (B) Top 100 abundant miRNAs classified by normalised counts (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0174514#sec002" target="_blank">Methods</a>) identified in exosomes isolated from EVT cells cultured under 1% or 8% oxygen. Hierarchical clustering of deep sequencing data was performed across exosomal miRNA samples. Normalisation of the reads was performed by DESeq2 using factors derived from the media ratio method.</p

miRNA profile in exosome present in maternal circulation at early gestation.

<p>(A) number of exosomes in normal, preeclampsia (PE) and spontaneous preterm birth (SPTB) at early gestation. (B) The Venn diagram shows the distribution of common and unique miRNA identified in exosomes present in maternal circulation in normal (EXO-NP), PE (EXO-PE) and SPTB (EXO-SPTB). (C) Top 100 abundant miRNAs classified by normalised counts (see <a href="http://www.plosone.org/article/info:doi/10.1371/journal.pone.0174514#sec002" target="_blank">Methods</a>) identified in exosomes isolated from maternal circulation. Hierarchical clustering of deep sequencing data was performed across exosomal miRNA samples. Normalisation of the reads was performed by DESeq2 using factors derived from the media ratio method.</p

Effect of oxygen tension on the size distribution of exosomes.

<p>Effect of oxygen tension on the size distribution of exosomes.</p

Levels of TNFα in exosome and cell-conditioned media.

<p>The concentration of TNFα was quantified in exososomes and EC-consitioned media using an ELISA kit. (A) Exosomes were isolated from EVT cells cultured at 8% and 1% oxygen and the concentration of TNFα was quantified in exosomes and in the soluble fractions (i.e. soluble). The soluble fraction was generated by ultracentrifugation at 100,000g (supernatant). (B) experimental design. (C) EC were cultured in the absence or in the presence of exosomes isolated from EVT culture at 8% or 1% oxygen for 24h and the concentration of TNFα was quantified in EC-derived exosomes and soluble fraction. (D) TNFα mRNA expression. Data represents n = 12 well for each point (6 different experiment in duplicate). Values are mean ± SEM.</p