VET656 Caesarean Delivery Practices In Nigeria Assessment 2 Answer

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Question :

Assessment 2. Critical Review of an Epidemiological Study

The written report should be of the highest standard of written scientific English and should display evidence of critical thinking and rigorous scientific consideration of the topic and appropriate references.The written critique must be no more than 2,500 words. The file MUST be uploaded as a word document

NOT .pdf Students are encouraged to explore different reporting guidelines relevant to the research paper they have chosen. There are multiple guidelines for conducting critical review, most of which are specific to the epidemiological study design.

Please select from one of the three published articles that details epidemiological research on an emerging, debatable, public health issue.

1. Beane Freeman, L. E., A.J. Deroos, S. Koutros, A. Blair, M. H. Ward, M. Alavanja, and J. A. Hoppin. 2012. "Poultry and livestock exposure and cancer risk among farmers in the agricultural health study." Cancer Causes Contro/ 23 (5):663-70. doi: 10.1007/s10552-012-9921-1.

2. Adewuyi, Emmanuel O, Asa Auta, Vishnu Khanal, Samson J Tapshak, and Yun Zhao. 2019. "Cesarean delivery in Nigeria: prevalence and associated factors—a population-based cross-sectional study." BM/ Open 9 (6):e027273. doi: 10.1136/bmjopen-2018-027273.

3. Girschik, J., J. Heyworth, and L. Fritschi. 2013. "Self- reported sleep duration, sleep quality, and breast cancer risk in a population-based case-control study." Am J Epidemiol 177 (4):316-27. doi: 10.1093/aje/kws422.

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Answer :

VET656 Public Health and Epidemiology

Assessment 2: Critical Appraisal of Emerging Public

Health Challenges

Article: Caesarean Delivery in Nigeria: Prevalence and Associated Factors―A Population BasedCross-Sectional Study 

Caesarean Delivery in Nigeria: Prevalence and Associated Factors―A Population BasedCross-Sectional Study 

By: Emmanuel O Adewuyi, Asa Auta, Vishnu Khanal, Samson J Tapshak, and Yun Zhao

General Description

The study article focuses on the prevalence of caesarean delivery practices in Nigeria and its other associated factors. The study was conducted on the basis of the population across sections. The purpose of this article was to investigate the practice conditions and frequency of caesarean deliveries in Nigeria and how it affects other adjacent aspects of health and society.

The central focus of the article is the life saving obstetric surgery known as Caesarean Section (CS), which is often conducted during emergency cases high-risk pregnancies. Such emergencies might include obstructed labour, large foetuses, breech presentations and even for women infected with HIV and AIDS (6). However, to this day, this essential surgery method lacks consensus around the world in terms of population-based prevalence. Although, statistically speaking, prevalence rate less than 5% is considered as unmet need whereas more than 15% has no significant benefit to the children or the mother. A population-based study in Nigeria revealed that the prevalence rate is well below the WHO recommended 10%, and there is no growth rate for the number of caesarean sections conducted across the country (2). These statistics suggest that maternal needs are unmet in the country and might have poor and neonatal outcomes. 

The selected article is very logically structured and constructed with a clear objective and design, followed by a brief background that explains the need for caesarean section in Nigeria. The methodology of the article describes the data sources and the sample size used for the study while also clearing out the variables. The data analysis section is also logically explained with the help of frequency tabulation and mentions how the citizens and patients of Nigeria contributed to the study. The article provides a detailed description of the results derived from the survey while also explaining in details the associated factors with caesarean deliveries in Nigeria. The article finishes off with a detailed discussion of the entire study, followed by a brief conclusion about the medical conditions of Nigeria that prevents the prevalence of CS deliveries. 

One of the major positive points about the articles is that it is written in a very clear, structured and understandable manner. This helps other researchers to grip the subject of the topic easily and utilise it for future studies. However, the statistics that represent the practices in Nigeria requires special skills to understand, although researchers are well versed in the topic. There are a few grammatical and spelling errors in the article, but being minor, they do not put an obstacle in understanding the study. 

Article Critique

Title and Abstract

The purpose of the title and abstract of the journal article is to provide a brief synopsis of the entire paper so that researchers can use a basic understanding of the entire paper by reading the title and abstract alone. It can be started from the title that it provides the type of study conducted and the topic of the paper in a clear and precise way. Researchers can derive that it is a population-based cross-sectional study about the prevalence of caesarean delivery in Nigeria from the title alone. The abstract, on the other hand, provides a summary of the entire paper with clear sections for objective, design, setting, outcome measures, results and conclusions. 

The article does not contain any key words sections that include the major keywords discussed in the article. However, given the conclusive nature of the abstract section, keywords are not that essential for the journal article. 


The introduction section of the article initiates with a background understanding of what a caesarean section is and how it is intervened in necessary cases. It also mentions the minimum rate of prevalence prescribed by WHO worldwide and other medical factors associated with it. It is followed by the prevalence of caesarean surgery in Nigeria and how it fails to meet the prescribed need for maternal care (3). In addition to this, it goes on to provide several other statistical pieces of evidence about the Nigerian medical care system and how it impacts the prevalence of CS delivery. The basic details about the survey conducted for the study have also been included in the introduction, which makes it appropriate to the paper's subject. The introduction part has been reviewed with the help of past literature, and scholarly articles which are peer-reviewed and thus makes them authentic. Moreover, the statistics provided in the introduction has been cited from other past research results, and thus, it is quite comprehensive. 

As a population-based cross-sectional study and data collected from a survey of Nigerian patients and citizens, the concept of the study is quite original and makes a convincing case. Although the aim of the study is not clearly mentioned in the introduction section of the article, the objectives provided in the abstract serves its purposes and has been derived logically from the literature. However, the article does not contain any stated hypothesis before the methodology and hence lacks a null hypothesis as well. Both the purpose of the hypothesis and the null hypothesis has been fulfilled by the article objective, which has been successfully met at the end. 

Materials and Methods

The design of the article follows a secondary analysis of the Nigerian Demographic and Health Survey (NDHS) data from 2013 to make it a population-based cross-sectional study. In addition to this, simple logistic regression was used along with multi-variable binary logistic regression that helped the analysis align with the research objective. Other design factors included X2 test and frequency tabulation of the prevalence of CS cases in Nigeria, which make the design of the article consistent with its aims. 

The methodology was not tested using a pilot study, although using logistic regression, and frequency tabulation served the purpose as they are highly accurate methodologies for performing secondary analysis. The survey included almost 40,320 representative households, although the interview was conducted on only 38,552 with a response rate of 99%. In any survey consisting of large enough sample size, control measures are necessary. For this study, however, the inclusion of dependent and independent variables were the only control measures which were used in the study. Based on the size of the sample, their response rate and the topic of the subject, using variables as controls for the study was adequate and did not require any further measures. As mentioned earlier, the total sample size, case studies and the control measures have been clearly mentioned in the article, which makes it quite convincing and accurate (7). Using the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) cross-sectional checklist for writing the report also acted as a major control measure.

The statistical evidence provided in the study from NDHS 2013 contains sufficient amount of details including the various time periods over which the studies were conducted, number of respondents and representative households and conclusive statistical tests that were conducted on them. Each of these factors is clearly stated in details in the article and are quite consistent throughout the article. However, the study does not mention any training or calibration of the enumerators or examiners who conducted the study on the selected sample size. The questionnaires and pro forma used for the study are quite relevant as revealed by the research outcome and results. Although, there is no mention of testing them before using them for the respondent households. Moreover, these questionnaires and pro forma used for interviewing the respondents have also not been included in the paper or its appendix or by any link provided in the article. This leaves a window of judgement about the validity and relevance of the questionnaires, although it can be overlooked due to the adequacy of the results derived from the data analysis.

At the end of the article, a clear segment has been provided about the ethical standards that were met for conducting the study. The Nigerian National Health Research Ethics Committee approved the ethical procedure for 2013 NDHS. Additionally, each participant provided a written consent form and parents of minors provided the same on their behalf. As anonymity was maintained for the secondary analysis, it did not require any further ethical clearance and Measure DHS/ICF International; the USA granted permission to use the data. 


The results of the data analysis and other statistical tests have been presented in a very structured, clear and unambiguous manner which make it very convincing for other researchers. The results section includes a sample characteristics section that clearly provides statistical evidence from the 2013 NDHS report. Each of the statistics has been provided using specific percentile representation to make it easily understandable. The results also include a prevalence of caesarean delivery section that provides a similar percentile representation of the survey conducted during the study. Furthermore, multiple tables and graphs have been provided to effectively summarise the entire study outcome and results in a structured and systematic manner. As per the knowledge of the researchers, there are not data missing from the article except for the pro forma and questionnaires used in the survey. Each of the statistical values, numbers and percentages used has been peer-reviewed and cited from authentic literary sources which make them accurate for the research topic. As all the statistical tests are either derived from 2013 NDHS or approved by them, they are quite appropriate for the case study (1). Provided that the sample size is almost 41,000, consisting of adults and minors of both genders, it can be stated that it is a large enough sample to justify the findings. However, being a population-based study, using a much larger sample size or including information from more sources would have been more appropriate to justify the findings. Based on the records recovered from Nigerian health-care centres, it can be stated that the findings are not only statistically accurate but clinically significant as well due to the validation from doctors conducting caesarean section delivery on the Nigerian women. Due to authentic citation and peer review, the results are quite believable in context to the research topic.

Discussion and Conclusion

There is a separate discussion section in the article after the results sections in which the researchers have described in details the prevalence of CS in Nigeria and how using multi-variable analysis helps in determining the odds of caesarean delivery when comparing rural and urban regions of Nigeria. Each of the aspects and design used for the methodology has been carefully critiqued by the researchers and has been discussed comprehensively. Multiple citations and reference to other important literature have been used throughout the discussion section, which makes it quite conclusive and convincing (5). The discussion section not only describes the research methodology and results of the article but also discussed the other factors associated with a low prevalence of CS in rural areas. Moreover, it provides a religious, cultural and demographic perspective on how they might affect the rate of CS deliveries in Nigeria (4). Similarly, even education has been considered as an important factor in determining how it might affect the prevalence of CS.

The article provides a separate conclusion section at the end of the paper to wrap up the final say about the study results and outcome. The conclusion section includes the effect of rural residence, Islamic religion and lack of health insurance as a driving factor for the lack of CS in Nigeria. It also involves a brief understanding of the necessity of women empowerment to intervene CS in Nigeria and states that the cost of CS has prevented its prevalence and should be made freely available for the benefit of the health. To summarise, it can be stated that the conclusion of the article is able to accurately reflect the study results and finding and wrap up the study on a conclusive note. 


Almost all of the references provided at the end of the article has been taken from journals and articles published over the last 4-5 years with a few exceptions in case of survey or statistics which were taken from the date they were last published in Nigeria. It can be concluded that all the references used for the article are relevant and accurate, although not all of them might be up to date. A total of 48 article references has been used through the research paper, which makes it very authentic, reliable and peer-reviewed. The use of such a large number of articles ensures the validity and authenticity of the research paper. 

Acknowledgements and Funding

At the end of the article, some extra information has been provided that includes essential information about the research paper like author affiliations, contributors along with acknowledgement and funding information. Special mention has been made about the DHS/ICF International, USA under the acknowledgement section for providing the NDHS dataset to the researchers. In addition to this, Adefemi Kazeem and Mary Adewuyi have also been mentioned who acted as the proofreader of the original manuscript of the article. 

As for the funding information, there was no mention of a specific grant offered to the authors of the article from any funding agency under the public, commercial or non-profit sector.

Over Assessment and Conclusion

Evaluating and critically analysing the entire article, it can be concluded that the researchers and authors of the article have done a great job in structuring and presenting the study in a clear and concise manner which makes it easy to understand. The article essentially includes all the relevant sections required for a research study with the exception of a few like evidence of pro forma and questionnaires used in the research. Moreover, due to the secondary analysis from 2013 NHDS and conducting a survey of 40,000 selected sample size, the article has indeed provided a clear population-based cross-sectional study of the prevalence of caesarean section deliveries in the urban and rural areas of Nigeria. The major plus point of the study is that it also provides the other associated factors related to CS like education, religion, economy, culture, etc. However, the limitation of the study remains in the fact that the analysed dataset is at least five years old and cannot reflect the current state of CS in Nigeria. However, due to its generalised nature and low missing data, it can be very well considered as a complete and conclusive report on the CS practices prevalent in Nigeria.