Impact of Prior Cesarean Section on Surgical Site Infections, Microbiological patterns, and Surgical Outcomes: A Prospective Multicenter Cohort Study in South Ethiopia

Impact of Prior Cesarean Section on Surgical Site Infections, Microbiological patterns, and Surgical Outcomes: A Prospective Multicenter Cohort Study in South Ethiopia | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Impact of Prior Cesarean Section on Surgical Site Infections, Microbiological patterns, and Surgical Outcomes: A Prospective Multicenter Cohort Study in South Ethiopia Mohammed Seid, Teshome Kebede², Aseer Manilal³, Dagimawie Tadesse, and 4 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-7502284/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 11 Feb, 2026 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted 18 You are reading this latest preprint version Abstract Background Cesarean section (CS) is a widely performed lifesaving surgical procedure; however, it may also carry risks of maternal complications, especially with repeated exposure. Evidence from prospective studies in low-resource settings is limited. This study provides insights to guide interventions and implement maternal health policies for women undergoing repeat CS in low-resource settings like Ethiopia Objective To assess whether prior CS increases the risk of postoperative surgical site infections (SSI), alters microbiological profiles, and contributes to intra- and postoperative complications compared with first-time CS. Methods A multicenter prospective cohort study was conducted from January to December 2022 among 1,506 women undergoing CS at one primary, one general, and one university comprehensive specialized hospital. Participants were enrolled into two cohorts: 753 women with ≥ 1 prior CS (exposed) and 753 undergoing first-time CS (unexposed). All participants were followed for 30 days postoperatively. The primary outcome was SSI; secondary outcomes included SSI type, microbiology, and perioperative complications. Data were analyzed using SPSS v25 with Poisson regression and robust variance estimators; p-value ≤ 0.05 was considered statistically significant. Results Overall SSI incidence was 13.5% (95% CI: 11.9–15.4%). Repeat CS had higher SSI rates than primary CS (20.3% vs. 6.8%; RR = 2.98, 95% CI: 2.20–4.03; p < 0.001 ), particularly deep incisional SSIs (30.1% vs. 9.8%; RR = 3.07; p = 0.012 ). Gram-negative isolates predominated in repeat CS (83.8% vs. 68.6%; p = 0.027 ). Adjusted analyses confirmed repeat CS as a strong independent predictor of SSI (aRR = 2.94, 95% CI: 2.20–3.93). Risk was highest in the university comprehensive specialized hospital and emergency CS. Women with ≥ 3 prior CS had nearly fourfold higher SSI risk. Repeat CS was also associated with longer operative time, greater use of general anesthesia, higher transfusion and antibiotic use, and longer hospital stay (p < 0.05). Additional independent predictors of SSI included emergency CS, history of hospitalization and aqueous povidone-iodine (10%) skin preparation with (aRR = 1.76, 95% CI: 1.06–2.91), (aRR = 1.56, 95% CI: 1.18–2.10), and (aRR = 2.39, 95% CI: 1.45–3.94), respectively. Conclusion Repeat CS is associated with a threefold higher risk of SSI, more severe complications, and Gram-negative predominance. Risk-stratified interventions, optimized infection prevention, careful surgical planning, and antimicrobial stewardship are essential to improve outcomes Cesarean section repeat CS surgical site infection maternal morbidity Ethiopia peripartum infections Figures Figure 1 Figure 2 Introduction Cesarean section (CS) is a fundamental surgical intervention in obstetrics, critical for reducing maternal and perinatal mortality in complicated pregnancies [ 1 ]. Originally reserved for life-saving indications, CS use has expanded worldwide due to factors such as perceived safety, convenience, and medico-legal pressures [ 2 ]. Consequently, global CS rates have more than doubled over the past 25 years, reaching 21.1%, well above the World Health Organization’s recommended rate of 10–15% [ 2 ]. A major contributor to this trend is the rising number of repeat cesarean deliveries (RCDs), which account for 15–68% of all procedures[ 3 ]. While CS is life-saving, it carries substantially higher risks than vaginal delivery. It is the single most important risk factor for postpartum infection, with surgical site infections (SSIs), endometritis, and urinary tract infections being the most common [ 4 – 6 ]. SSIs lead to prolonged hospitalization, increased healthcare costs, higher antibiotic use, and long-term sequelae including chronic pelvic pain, secondary infertility, and wound dehiscence [ 5 , 7 , 8 ]. In low- and middle-income countries (LMICs) such as Ethiopia, post-CS SSI incidence ranges from 9.7–25.4%, placing additional strain on already fragile health systems [ 9 ]. The risk of maternal complications increases substantially with a history of prior CS. Previous CS is consistently identified as a strong independent risk factor for postoperative morbidity, nearly tripling the risk of infection due to altered tissue planes, adhesions, and longer operative times [ 3 , 4 , 6 ]. Repeat CS is also associated with greater surgical complexity, including adhesiolysis, increased blood loss, and longer operative time, which heightens intraoperative and postoperative complications [ 3 , 10 ]. Furthermore, the microbiological profile of SSIs is evolving in LMICs, with multidrug-resistant Gram-negative pathogens, particularly Escherichia coli and Klebsiella pneumoniae , increasingly complicating management [ 5 , 8 ]. Despite the growing prevalence of repeat CS and associated maternal risks, robust prospective data comparing primary and repeat CS outcomes in Ethiopia remain scarce. Most existing studies are retrospective or single-center, limiting their generalizability [ 9 ]. Moreover, few studies provide detailed microbiological characterization of SSIs or explore modifiable risk factors in this context [ 5 ]. Addressing this gap, the present prospective cohort study aims to assess the impact of prior CS on maternal complications, with a primary focus on 30-day SSI incidence. Secondary objectives include evaluating severity, microbiological profiles, intraoperative challenges, such as prevalence of adhesions, operative time, anesthesia type, and blood transfusion; and postoperative outcomes, such as hospital stay, continued antibiotic use, and readmission. Subgroup analyses will explore the influence of key patient mix factors on SSI risk. Key findings of this study will inform targeted infection prevention, antibiotic stewardship, and surgical planning to reduce maternal morbidity in Ethiopia and comparable LMIC settings Materials and methods Study design, setting, and durations This prospective cohort study was conducted between January and December 2022 across three purposively selected government hospitals located within the South Ethiopian Regional State. These are Gidole Primary Hospital in Gardula Zone, Arba Minch General Hospital in Gamo Zone, and Wolayita Sodo University Comprehensive Specialized Hospital (WSUCSH) in Wolayita Zone. These zones were selected based on their geographic proximity, population characteristics, and healthcare infrastructure, facilitating efficient data collection and follow-up. Hospital volume was defined as the mean annual number of CS procedures between 2021 and 2022, and hospitals were selected using three key criteria: (1) their level within Ethiopia's healthcare hierarchy, (2) an annual CS volume, and (3) geographic representation. The selection of hospitals in this study was based on a tiered selection approach, which included primary hospitals, general hospitals, and teaching and referral hospitals. Populations The target population for this study comprised women with singleton pregnancies who underwent cesarean section (CS) at the participating hospitals and delivered at term. The study population comprised all women >18 years of age admitted for elective or emergency CS at labor and obstetric wards during the study period in the selected hospitals and fulfilled the eligibility criteria. The study population in the study cohort was defined based on the primary exposure or factor variable (number of prior CS). Exposure cohort or study group: Multiparous pregnant women who had a history of previous CS and were further stratified as repeat CS (one or two previous CS) and multiple repeat (≥3 prior CS). The comparator cohort (C) comprised all women with first-time CS (primary CS); this group was used as a baseline comparison to contextualize the maternal morbidity associated with repeat CS. Figure 1 displays the population flow chart of subjects and exclusion criteria in the present analysis. Eligibility criteria Inclusion criteria (both exposed and comparison cohorts): Women were eligible if they were aged 18 years or older, had a singleton pregnancy, attended the obstetric ward and labor room, underwent elective or emergency CS (for any indications), provided written informed consent (surrogate consent), and resided within the follow-up area or were reachable by phone during postoperative follow-up of at least 30 days [11]. Exclusion criteria: Women were excluded if they had an active infection at the time of surgery, including clinical sepsis, chorioamnionitis (fever, fetal tachycardia, increased HSCRP, uterine tenderness, foul-smelling discharge), or an unresolved surgical wound infection from a prior operation. Additionally, women referred after undergoing CS at another facility and women who had concurrent surgery were excluded due to incomplete preoperative and intraoperative data. Cases with missing or incomplete medical records, as well as participants, who could not be followed for the whole 30-day surveillance period because of relocation, incorrect contact information, or voluntary withdrawal, were also excluded. Women who were critically ill or had a major psychiatric illness were excluded. Sample size and sampling techniques The sample size was calculated using the two-population proportion formula [12] in OpenEpi. In this calculation, p₁ represented the incidence of SSI in the baseline population and p₂ the incidence among women with a prior cesarean section. We assumed a significance level of 5% (Zα = 1.96) and a power of 80% (Zβ = 0.84). A baseline incidence of SSI following cesarean section was taken as 11% [9]. Previous studies have reported that repeat cesarean delivery increases the risk of SSI by 1.2–2-fold [5, 13, 14]. For this study, we planned to detect an increase of 1.47 (i.e., from 11% to 16.2% as a clinically meaningful estimate within that reported range). With a 1:1 ratio of exposed to non-exposed groups, the minimum required sample size was 1,376 women (688 per group). To account for potential loss to follow-up or incomplete data, a 10% contingency was added, yielding a final required sample size of 1,514 participants (757 per group). However, during the one-year study period, the total participants enrolled in the study were n = 1,506 (a total of 753 per group). Sample allocation and sampling procedure The final study sample comprised 1,506 women, equally divided into two groups: 753 undergoing their first cesarean section (primary CS group, controls) and 753 with one or more prior cesarean deliveries (repeat CS group, exposed). A 1:1 ratio was maintained to allow balanced statistical comparisons between groups. To ensure representativeness across the regional healthcare system, the sample was proportionally allocated to the three participating hospitals according to their annual cesarean delivery volume. Based on this approach, the final sampled participants by hospitals were: Gidole Primary Hospital (annual volume 460) contributed 211 participants, Arba Minch General Hospital (annual volume 1,043) contributed 477 participants, and Wolayita Sodo University Comprehensive Specialized Hospital (annual volume 2,084) contributed 818 participants. Within each hospital, participants were selected using stratified systematic sampling techniques. Within each stratum defined by hospital and CS type, systematic random sampling was applied. The sampling frame was prepared using the previous year’s cesarean section records from each hospital to estimate the number and flow of eligible women during the study period. Based on this, the total number of eligible women for each hospital was determined, and the hospital-specific sample size was allocated proportionally. A systematic sampling approach was then employed: the sampling interval ( k ) was calculated by dividing the total number of eligible women by the allocated sample size. The first participant was randomly selected using a lottery method, and every k th eligible woman thereafter was enrolled until the required sample size was reached. If a selected participant was ineligible or declined participation, the subsequent k -th eligible woman was included, ensuring unbiased selection without replacement (see participant flow chart , Figure 1). Study variables (exposure, outcome, and covariates) Primary exposure/factor variables assessment The primary exposure of interest in this study was a previous history of cesarean section (CS). This variable was defined as whether a woman had undergone one or more CS deliveries prior to the index operation during the study period. Information on prior CS history was obtained from medical records and confirmed through participant interviews at enrollment. For analysis, exposure was categorized into two groups: the exposed group, women with a documented prior history of at least one previous CS, and the unexposed group, women undergoing their first CS (no previous history of CS). For subgroup and sensitivity analyses, the number of prior CS deliveries (one, two, or ≥ three) was also recorded to explore the possibility of a dose-response relationship between repeated cesareans and maternal complications. Primary and secondary outcomes The primary outcome was SSI diagnosis within 30 days of CS delivery. SSI diagnosis was based on criteria aligned with the recommendations of the National Healthcare Safety Network of the Centre for Disease Control and Prevention (CDC) [11]. The treating clinician or gynecologist made diagnoses through review of patients' charts, medical records, and microbiological data, and the investigator subsequently verified these. The outcome was recorded as a binary variable (present/absent). The primary metric was the cumulative incidence proportion (risk) of SSI among women with a prior cesarean section who underwent CS during the study period, expressed as a percentage with 95% confidence intervals (CI). Secondary outcomes were the type of SSI (superficial incisional vs. deep incisional. The other pre-specified secondary outcomes included the intraoperative events such as duration of surgery, intraoperative blood transfusion, prevalence of intra-abdominal adhesion, placental previa, and others in the postoperative phase; culture positivity of wound samples, microbial profile of SSI, length of hospital stay, postoperative antibiotic use, re-admission to hospital, and mortality. A secondary outcome also included risk factors for SSI after CS [15] Covariates/risk factors and potential confounders Potential covariates considered in the analysis were grouped into demographic, obstetric/clinical, and operational/procedural factors. Demographic factors were age group (30 years), residence (urban or rural), body mass index, alcohol, and tobacco use. Obstetric and clinical factors comprised parity status (primiparous, multiparous, or grand multiparous), referral status (yes/no), antenatal complications such as labor before CS, duration of labor (in hours), presence of membrane rupture before CS and durations, vaginal examinations (yes/no), number of vaginal examinations, history of hospitalization (90 days) (yes/no), and underlying medical conditions (presence, number, and type). Procedure-related factors were urgency (emergency vs. elective CS) and type of incision (Pfannenstiel(Transverse) vs. vertical midline), intraoperative events such as blood transfusion (yes/no), surgical hand scrub method (plain soap and water vs. antiseptic hand rub), preoperative skin preparation (aqueous povidone-iodine (10%), iodine + alcohol vs. chlorhexidine alcohol), skin closure type (interrupted vs. other), duration of operation (min), grade of surgeon, surgical antibiotic prophylaxis use (type, timing, and dose), and use of anesthesia (general vs. spinal). These covariates were selected based on clinical relevance and potential to confound the association between cesarean section type and surgical site infection. Operational definitions The presence of pre-existing medical conditions was defined as the presence or absence of any of the following: hypertension, anemia, diabetes mellitus, malaria or acute febrile illness, or the presence of any chronic systemic disease like HIV, renal disease, heart disease, or liver disease. [24] Repeat caesarean section (CS) was defined as any caesarean delivery performed in a woman who has had at least one previous CS [3] and Multiple repeat CS was defined as three or more previous CS deliveries [16]. Study procedures Enrollment, Consenting & Follow-up Participants were enrolled preoperatively (at admission to the obstetrics ward and labor room) following written informed consent, and the eligibility criteria were fulfilled and followed for 30 days post CS delivery. All eligible women scheduled for cesarean section (CS) delivery during the study period were consecutively approached for enrollment. Recruitment was carried out in the obstetrics and gynecology ward by trained research nurses who worked in close collaboration with the clinical care team to identify potential participants before surgery. Women were approached in the preoperative period, provided with a brief explanation of the study objectives, procedures, risks, and potential benefits, and were given adequate time to ask questions. Written informed consent was obtained from each participant prior to enrollment. For women who could not read or write, the consent form was read aloud in the local language by a trained staff member, and a literate witness not directly involved in the study confirmed the participant’s decision by signing the consent document. Participants were assured that their decision to take part or not would not affect their medical care in any way. Confidentiality of personal and clinical information was strictly maintained by using unique study identifiers and restricting data access to authorized study personnel only. Enrolled women were followed from the time of the index CS through 30 days post-operation to monitor for surgical site infection (SSI) and other maternal complications. Follow-up was conducted through daily ward visits during admission, review of hospital records, and scheduled outpatient or telephone follow-up after discharge. The enrollment strategy aimed to include all eligible participants within a fixed period, as recommended by the WHO [17]. However, due to logistical and feasibility concerns, a total of 1506 participants were systematically selected and enrolled into either the exposure or comparison cohort in a 1:1 ratio. For each repeat CS, the first time CS was enrolled. Enrollment occurred at the time of observation and included days, nights, and weekends. Each eligible consented participant was assigned a unique study identification number, and all baseline and follow-up data were collected using a pretested tool. Data collection procedures Data source, collection tools, and methods Essential data were collected before and during surgery, using information obtained directly from patients, operation notes, anesthesia records, medical and medication charts, and direct observations. Data were collected prospectively from women who underwent cesarean section at three public hospitals in southern Ethiopia through physical or clinical examinations, structured interviews (socio-demographics, behavioral and obstetric history), and hospital record reviews (clinical, laboratory, and operation-related data). A semi-structured questionnaire, case report form, data abstraction form, and a standardized SSI checklist were developed after reviewing literature and guidelines [17, 18] and pretested and used to collect socio-demographic, behavioral, obstetric, clinical, and operation-related data (preoperative, intraoperative, and postoperative) from patient interviews and medical records. Data were collected by trained research assistants (an obstetrician, a gynecologist, a midwifery nurse, and a medical microbiologist) after written informed consent was obtained. Baseline data collection procedures Data were collected using a structured case report form (CRF) developed specifically for the study. The Case report form (CRF) was pretested on a small group of participants to ensure clarity and completeness, and minor modifications were made before use in the main study. Data collection was carried out by trained research nurses and midwives who were not part of the surgical team to minimize observer bias. Baseline data were obtained preoperatively through direct interview and review of medical records. This included socio-demographic information (age, residence, educational status, occupation), obstetric history (gravidity, parity, history of previous cesarean delivery, antenatal care attendance), existing medical history (diabetes mellitus, hypertension, HIV status), and indication for the current CS. Surgery related data collections These included type of cesarean section (elective or emergency), duration of surgery, blood loss, type of anesthesia, surgeon’s level of experience, use of surgical antimicrobial prophylaxis, and intraoperative complications. All women enrolled in the study were followed for 30 days after cesarean delivery to ascertain the occurrence of surgical site infections (SSIs) and other postoperative complications. Follow-up began on the day of the operation (day 0) and continued until the end of the 30-day period or until the patient was lost to follow-up. In-hospital follow-up: During the immediate postoperative period, daily clinical assessments were conducted by trained research nurses until discharge. Data on vital signs, wound appearance, pain, fever, antibiotic administration, and other maternal outcomes were documented. Any suspected infection was evaluated in collaboration with the attending physician, and wound swabs were collected for microbiological analysis where indicated. Post-discharge follow-up: After discharge, women were actively followed up through a combination of scheduled outpatient clinic visits (typically on postoperative days 7, 14, and 30) and telephone follow-up as per the protocol Confirmation of outcomes: S SSIs were defined and classified according to the Centers for Disease Control and Prevention (CDC) criteria (superficial incisional, deep incisional, or organ/space). For each suspected case, a standardized assessment checklist was applied. Microbiological confirmation was sought whenever possible. Follow-up completeness and retention strategies: To minimize loss to follow-up, detailed contact information was collected at enrollment, including mobile phone numbers of participants and close relatives. Reminder calls were made before scheduled visits, and transportation reimbursement was provided where necessary. If participants could not attend the clinic, assessments were made via structured phone interviews, and if infection was suspected, arrangements were made for facility-based evaluation. Microbiological methods Sample collection, transport, and processing: Clinical specimens (wound swabs and aspirates) were collected aseptically from women presenting with signs of post-operative infection following CS by trained health care personnel (microbiologist, midwifery nurse, or clinicians/ obstetricians aseptically following standard protocol and procedures[17]. All specimens were promptly transported to the microbiology laboratory under appropriate temperature-controlled conditions maintain viability. Culture and isolation of bacteria were performed through conventional culture and biochemical test following the standard microbiological techniques [19]. Upon receipt, each specimen was inoculated onto 5% sheep blood agar, MacConkey agar, mannitol salt agar, and chocolate agar and the first two were incubated aerobically at 35–37°C for 24–48 hours, whereas chocolate agar plates were incubated with 5-10% CO₂ using a candle jar alongside other plates for 24–48 hours at 35–37°C [19]. Identification of Isolates —Bacterial isolates were identified using conventional culture techniques and battery of standard biochemical assays. Colony morphology, hemolysis, pigmentation, and Gram stain were used for preliminary differentiation of isolates. Identification of Gram-positive cocci was carried out using catalase and coagulase tests for Staphylococcus aureus , and bile esculin hydrolysis, and salt tolerance test for Enterococcus species. Gram-negative bacilli were identified through a panel of conventional biochemical tests including oxidase, triple sugar iron (TSI) agar, IMVIC ((Indole, Methyl Red, Voges–Proskauer, Citrate utilization), urease, motility, and hydrogen sulfide production, and carbohydrate fermentation tests. Species identifications and interpretation of test results were according to Bergey's Manual of Systematic Bacteriology [20]. Laboratory findings were systematically recorded and linked with clinical data to confirm infection status. Quality assurance To ensure data quality, comprehensive training was provided before study initiation on data collection tools, surveillance methods (including participant recruitment, consent procedures, and follow-up), data recording, and microbiological techniques. A pretest was conducted on 5% of the sample at Chencha Hospital, which was not part of the main study. The questionnaire was initially developed in English, translated into the local language, and then back-translated to English to ensure accuracy. Laboratory test reliability was maintained through rigorous quality control measures, including the use of reference strains Pseudomonas aeruginosa (ATCC 27853) and Escherichia coli (ATCC 25922) procured from the Ethiopian Public Health Institute (EPHI). The principal investigator conducted daily quality control check and sterility and performance of culture media were checked for each batch. Data checks for completeness, clarity, and consistency, and standard operating protocols were strictly followed for all laboratory procedures [21]. Data management and statistical analysis Data were entered into EpiData (CDC, USA) and exported to SPSS version 25.0 (IBM Corp., Chicago, IL) for analysis. Baseline characteristics were summarized using descriptive statistics: categorical variables were presented as frequencies and percentages, and continuous variables as means with standard deviations (±SD) or medians with interquartile ranges (IQR), depending on data distribution. The Shapiro–Wilk test was used to assess normality of continuous variables. Group comparisons were performed using the independent t-test for normally distributed variables and the Wilcoxon rank-sum test for non-normally distributed variables. Categorical variables were compared using the chi-square (χ²) test or Fisher’s exact test, as appropriate. Comparisons were first made between women with prior cesarean section (repeat CS) and those undergoing first-time CS on baseline socio-demographic and obstetric characteristics. Case-mix factors considered included socio-demographic characteristics (age, residence), medical and obstetric factors (body mass index [BMI], comorbidities, prior hospitalizations, rupture of membranes, antenatal care attendance, labor characteristics), history of prior CS, operative-related factors (urgency, duration, infection prevention practice), and environmental factors (hospital type). Subgroup analyses of the primary outcome (surgical site infection, SSI) were performed by hospital type, urgency of CS (elective vs. emergency), obesity status (BMI 18 h), presence of pre-existing medical conditions, and type of preoperative skin preparation (povidone iodine, iodine + alcohol, or chlorhexidine–alcohol). To identify risk factors for SSI, Poisson regression with robust variance estimators was used to estimate relative risks (RRs) and adjusted relative risks (aRRs) with 95% confidence intervals (CIs). SSI was modeled as a binary outcome, with the number of prior CS (first CS vs. repeat CS) as the primary exposure of interest. Potential confounders were identified based on prior literature and biological plausibility, and included demographic, obstetric/clinical, and procedural variables. Demographic variables included age group (30 years), residence (urban vs. rural), education level, obesity status (BMI 24 h), rupture of membranes, prior hospitalization, comorbidities (HIV, hypertension, diabetes, and anemia), emergency CS, and type of incision. Procedural and operational factors included number of vaginal examinations, intraoperative transfusion, surgical hand scrub method, preoperative skin preparation, skin closure type, antibiotic prophylaxis, and anesthesia type. Covariates were first assessed in bivariate analyses and those with a p-value <0.20 were considered for inclusion in multivariable models. The final adjusted Poisson regression model included type of CS and all significant covariates. Two-sided p-values <0.05 were considered statistically significant Results Study participant flow in the study During the study period, a total of 3,587 women undergoing cesarean section were assessed for eligibility across three hospitals: Gidole Primary Hospital (n = 460), Arba Minch General Hospital (n = 1,043), and Wolayita Sodo University Comprehensive Specialized Hospital (n = 2,084). Of these, 102 were excluded (9 from Gidole, 37 from Arba Minch, and 56 from Wolayita Sodo), resulting in 3,485 eligible women. From the eligible population, 1,506 participants were enrolled using proportional allocation and systematic random sampling, with equal distribution between women undergoing their first cesarean section (n = 753) and those with a prior history of CS (n = 753). The allocation by hospital was as follows: first CS—128 at Gidole, 238 at Arba Minch, and 387 at Wolayita Sodo; women with prior history of CS (repeat CS group)=83 at Gidole, 239 at Arba Minch, and 431 at Wolayita Sodo. All enrolled women were followed for 30 days after surgery, including 211 from Gidole, 477 from Arba Minch, and 818 from Wolayita Sodo. The primary outcome, surgical site infection, was documented in 204 participants, of whom 181 had microbiologically confirmed infections (Figure 1). Baseline characteristics of the study participants At baseline, the two cohorts were broadly comparable in socio-demographic characteristics (TableS1). Women undergoing repeat CS were older on average than those with a first CS (30.1 ± 5.6 vs. 26.9 ± 5.0 years, p<0.001 ), though age-category distributions (<30 vs. ≥30 years) were similar (p=0.998). Residence and education were evenly distributed across groups, with nearly half residing in urban areas and over one-third having attained college-level education. Mean BMI was slightly higher in the repeat CS group (25.9 ± 4.3 vs. 24.8 ± 3.7, p<0.001 ), but obesity prevalence was identical (4.9%). In contrast, obstetric and clinical profiles differed. Referrals were more frequent among repeat CS women (42.4% vs. 34.5%, p=0.002 ). As expected, parity distributions diverged significantly, with most first CS cases being primiparous and most repeat CS cases multiparous or grand multiparous (p<0.001). ANC attendance was high overall, though ≥4 visits were more common in first CS (75.2% vs. 58.8%, p<0.001 ). At presentation, first CS cases were more often in labor (79.7% vs. 73.0%, p=0.003 ), while prolonged labor and prior hospitalization were more common in repeat CS (both p<0.05 ). Membrane rupture before surgery (65.1% vs. 46.5%) and multiple vaginal examinations (86.4% vs. 69.1%) were also more frequent in repeat CS (p<0.001). Pre-existing medical conditions were reported at similar rates across groups, with no significant differences in hypertension, anemia, HIV, diabetes, hepatitis B, or malaria. Intraoperative, emergency CS predominated in first CS (88.7% vs. 65.1%, p<0.001), while elective procedures were more common in repeat CS (34.9% vs. 11.3%). General anesthesia was used more frequently in repeat CS (20.6% vs. 15.9%, p=0.030 ). Skin preparation practices differed, with alcohol + iodine more common in repeat CS and chlorhexidine + alcohol in first CS (both p97%). Detailed baseline characteristics are provided in the additional file (Supplementary Tables S1) Incidence of Post-CS Surgical Site Infections (SSIs) Among the 1,506 women who underwent CS, the overall cumulative incidence of surgical site infection (SSI) was 13.5% (204/1,506; 95% CI: 11.9–15.4) after a mean follow-up of 13.7 ± 2.9 days. SSI risk was significantly higher in women with a prior CS compared to first-time CS (20.3% vs. 6.8%), corresponding to a relative risk (RR) of 2.98 (95% CI: 2.20–4.03) and a risk difference (RD) of 13.5% (95% CI: 10.1–16.9%; p < 0.001). Superficial incisional infections accounted for 75.0% of all SSIs, while deep incisional SSI accounted for 25.0%. Deep incisional SSI was more frequent in the repeat CS group (30.1%) than in the first CS group (9.8%) (RR: 3.07; 95% CI: 1.28–7.36; RD: 20.3%; 95% CI: 9.4–31.2%; p = 0.012 ). The timing of SSI early (before discharge) versus post-discharge—was similar between groups (early: 37.9% vs. 37.3%, RR 1.02, 95% CI: 0.66–1.58; p = 0.870; post-discharge: 62.1% vs. 62.7%, RR 0.99, 95% CI: 0.74–1.34; p = 0.940 ). The mean time to SSI onset was significantly longer in repeat CS women (15.9 ± 2.9 days) compared to first CS women (7.1 ± 2.9 days; p < 0.001 ). Of the 204 wound samples, 88.7% (181/204) were culture-positive, yielding 211 bacterial isolates. Monobacterial infections predominated (83.4%), with Gram-negative bacteria accounting for 79.6% of isolates. Gram-negative infections were more frequent in repeat CS women (83.8% vs. 68.6%; RR: 1.22, 95% CI: 1.00–1.49; p = 0.027 ). Gram-positive isolates were detected in 37.0% of cases, more commonly among first CS women (45.1% vs. 33.8%; p = 0.127 ). Mixed Gram-negative and Gram-positive infections were uncommon (12.7%). Superficial SSIs were less frequent in repeat CS women (69.9%) than first CS women (90.2%) (RR: 0.78; 95% CI: 0.66–0.91; p = 0.002 ), whereas deep incisional SSI was more frequent in repeat CS women (30.1% vs. 9.8%; RR: 3.07; 95% CI: 1.28–7.36; p = 0.012). Surveillance indicated that 40.7% of SSIs were identified before discharge and 59.3% after discharge, with no significant differences between groups (p > 0.05). Detailed microbiological patterns are summarized in Table 1. Table 1 : Incidence of SSIs by type of CS (first CS vs. women with prior history of CS ( repeat CS cohort) in a cohort of 1506 women who underwent CS delivery at three selected hospitals Outcomes All Comparison group Relative risk (95% CI) Risk difference (95% CI) p-value Priory CS (≥1) (n=753) First CS (n=753) No (%) No (%) No (%) Any SSI 204 (13.5) 153 (20.3) 51 (6.8) 2.98 (2.20–4.03) 13.5 (10.1–16.9) <0.001 Depth and severity of SS after CS Superficial SSI 153(75) 107 (69.9) 46 (90.2) 0.78 ( 0.66-0.91) 0.002 Deep incisional 51 (25) 46(30.1) 5(9.8) 3.07 ( 1.28-7.36 ) 20.3 (9.4–31.2) 0.012 Time to onset( X ± SD) 13.7 ± 2.9 15.9 ± 2.9 7.1 ± 2.9 <0.001* Distribution of early vs. late SSI SSI before discharge 83 (40.7) 58 (37.9) 19 (37.3) 1.02 (0.66–1.58) 0.870 SSI post-discharge 121 (59.3) 95 (62.1) 32 (62.7) 0.99 (0.74–1.34) 0.940 Microbiological findings Culture confirmed SSI 181/204 153(85.0) 51(100.0) 0.85( 0.78-0.92) −15.0 (−20.2 to −9.8) <0.001 Monobacterial infection 151 (83.4) 109 (83.8) 42(82.4) 1.02(0.87-1.19) 0.82 Gram negative bacteria 106 (58.6) 81 (74.3) 35(68.6) 1.22 (1.00-1.49) 5.7 ( −9.4 to 20.8) 0.027 Gram positive bacteria 45 (24.9) 28 (25.7) 23(45.1) 0.75 (0.51-1.11) 0.127 Polymicrobial infections 30 (16.6) 21 (16.2) 9(17.6) 0.92 (0.45-1.87) 0.81 Note: SSI = surgical site infection. P-values are based on chi-square (χ²) tests for categorical variables and independent-samples t-tests for continuous variables. Bold values denote statistical significance at the p-value <0.05 level. Subgroup variations in the effect of previous history of CS on SSIs A pre-planned subgroup analysis was conducted to evaluate whether the association between prior history of cesarean section (repeat CS cohort) and SSI was consistent across different patient populations and clinical settings. The results demonstrated that the magnitude of SSI risk varied by hospital type, type of CS, BMI, underlying medical conditions, and preoperative skin preparation method. Women delivering in referral and teaching hospitals experienced the highest increase in SSI risk associated with prior CS (RR: 4.30; 95% CI: 2.72–6.80), whereas the risk was lower and not statistically significant in primary hospitals (RR: 1.67; 95% CI: 0.81–3.45; p-interaction = 0.025). Emergent CS procedures were associated with a higher SSI risk compared to elective CS. Among women with BMI <30 kg/m², prior CS markedly increased SSI risk (RR: 4.20; 95% CI: 2.88–6.12), while no significant risk increase was observed in women with BMI ≥30 kg/m². Similarly, the risk increase was more pronounced in women without underlying medical conditions (RR: 3.54; 95% CI: 2.32–5.40; p-interaction <0.001). Regarding preoperative skin preparation, aqueous povidone-iodine was associated with the highest SSI risk in the repeat CS cohort (RR: 4.93; 95% CI: 2.83–8.60), whereas chlorhexidine-alcohol served as the reference with the lowest SSI rates. No significant effect modification was observed for prolonged rupture of membranes (PROM) status (p-interaction = 0.22), indicating that prior CS increased SSI risk regardless of PROM. Overall, our analysis indicate that repeat CS is a strong independent risk factor for SSI, and its impact is influenced by patient, procedural, and hospital-related factors. Intraoperative Complications and surgical outcomes by type of CS Among the secondary outcomes, significant differences were observed between women who underwent repeat cesarean section (CS) and those with a first CS (Table 3). The use of general anesthesia was higher in the repeat CS group (20.6%) compared to the first CS group (15.9%), with a 30% increased risk (RR = 1.30, 95% CI: 1.05–1.61, p = 0.018 ). The mean operative time was markedly longer in women with repeat CS (59.0 ± 11.0 minutes) than in those undergoing a first CS (40.1 ± 9.0 minutes) (p < 0.001). Intra-operative maternal complications were also more frequent in the repeat CS group. Blood transfusion or significant bleeding occurred in 23.9% of repeat CS compared with 13.9% in first CS, corresponding to a 71% higher risk (RR = 1.71, 95% CI: 1.43–2.06, p < 0.001). Dense adhesions were detected in 4.8% of women with repeat CS compared with only 0.4% among first CS (RR = 12.0, 95% CI: 3.7–38.4, p < 0.001 ). Placenta previa was also more common in the repeat CS group (2.0% vs. 0.7%; RR = 3.0, 95% CI: 1.1–8.1, p = 0.030). Regarding post-operative outcomes, prophylactic use of systemic antibiotics was substantially higher in women with repeat CS (97.6%) than in those with first CS (58.9%) (RR = 1.65, 95% CI: 1.57–1.75, p < 0.001 ). The mean hospital stay was significantly prolonged among repeat CS patients (3.8 days vs. 1.3 days, p < 0.001 ). Moreover, hospital readmissions were almost threefold higher in the repeat CS group compared to first CS (12.6% vs. 4.2%; RR = 2.97, 95% CI: 1.99–4.45) Table 3 : Maternal complications, intraoperative events, and post-operative outcomes among women undergoing repeat CS (n=753) compared with first CS (n=753) at three hospitals in South Ethiopia Secondary outcomes All Repeat CS First CS (control) RR(95%CI) p-value No (%) No (%) No (%) Intraoperative events General anesthesia used 275 (18.26) 155 (20.6) 120 (15.9) 1.30(1.05-1.61) 0.018 Operation time(min) (Mean ± SD) 49.56 ± 11.5 59 ±11 40.12±9 <0.001 Intra-operative maternal complication Blood transfusion/bleeding 285 (18.9) 180 (23.9) 105 (13.9) 1.71(1.43-2.06) <0.001 Dense adhesion 39(2.5) 36(4.8) 3(0.4) 12.0(3.7–38.4) <0.001 Placenta previa 20(1.3) 15(2.0) 5(0.7) 3.0 (1.1–8.1) 0.03 Post-operative complications in the hospital Post-operative SAP 1178(78.3) 735 (97.6) 444 (58.9) 1.65(1.57-1.75) < 0.001 Length of hospital stay 2.6 days 3.8 days 1.3 days - <0.001 Readmission for any reason 121 (8.03) 95 (12.6) 32 (4.2) 2.97(1.99-4.45) <0.001 Note : Reaped CS group combined all women who had any previous CS, RR ; Relative Risk, SAP; surgical antibiotic prophylaxis, CS ; cesarean section Bold values denote statistical significance at the p-value <0.05 level Microbiology of SSI after CS by first time and repeat CS Of the 181 culture-proven SSI, 106 (58%) were caused by pure Gram-negative bacilli, predominantly Klebsiella pneumoniae (26.0%), Pseudomonas aeruginosa (14.4%), and Escherichia coli (12.7%). Gram-positive bacteria accounted for 24.9% of SSIs, predominantly Staphylococcus aureus (15.5%), followed by coagulase-negative staphylococci (CoNS) (6.1%) and Enterococcus faecium (3.3%). A statistically significant difference was observed in the bacterial profile of SSI due to monobacteria between first and repeat CS groups; with Gram-negative isolates more frequent among repeat CS patients, whereas Gram-positive bacteria were relatively more common in first-time CS. Among polymicrobial infections, the most frequent combinations included P. aeruginosa with S. aureus (6.1%), E. coli with K . pneumoniae (4.4%), and K. pneumoniae with S. aureus (2.2%). These patterns suggest a diverse microbial etiology, with a predominance of Gram-negative bacteria in repeat CS-related SSIs and notable Gram-positive contributions in first-time CS infections. Detailed distribution of individual pathogens by cesarean section type is presented in Figure 2 Effect of priory CS on the incidence of SSI In bivariate analyses using Poisson regression with robust variance, all variables with p < 0.25 were considered as candidates for the multivariable model. These included age, residence, prolonged labor, BMI, prior hospitalization, being in labor at CS, vaginal examinations, urgency of the procedure, general anesthesia, and preoperative skin preparation. In the multivariable model, repeat CS was the main exposure of interest, and the other variables were included as covariates to control for potential confounding. After adjustment, repeat CS remained strongly associated with an increased risk of SSI (adjusted RR = 2.94, 95% CI: 2.20–3.93, p < 0.001 ). Other factors that were independently associated with SSI included prior hospitalization (adjusted RR = 1.56, 95% CI: 1.18–2.10, p = 0.002 ), emergency CS (adjusted RR = 1.76, 95% CI: 1.06–2.91, p = 0.03 ), and preoperative skin preparation with aqueous povidone-iodine (10%) (adjusted RR = 2.12, 95% CI: 1.41–3.19, p = 0.001 ) ( Table 4). Table 4 : Bivariable and multivariable analysis of risk factors associated with SSI after CS among women underwent at three hospitals in the south Ethiopia region Characteristics All (n) SSI (Yes) Crude RR (95% CI) p-value Adjusted RR (95% CI)* p-value No (%) Repeat CS (≥ 1CS) (yes/no) (753)/(753) 153(20.3)/51(6.8) 2.98 (2.21–4.02) <0.001 2.94 (2.20–3.93) 30 years (vs. < 20 years) 429 (28.5) 79/ (18.4) 1.32 (0.97–1.80) 0.08 NS Residence (Urban/Rural) 710/796 84 (11.8)/ 20(15.1) 1.28 (0.95–1.72) 0.11 NS BMI (per 1-unit increase) (1506) 204(13.5) 1.04 (0.99–1.09) 0.06 1.04 (0.99–1.09) 0.05 Prior hospitalization (Y/N) (204)/(1302) 62 30.3)/142(10.9) 2.79 (1.28–2.97) 0.002 1.56 (1.18–2.10) 0.002 Prolonged labor >24h(Y/N) 115 (7.6) 32(27.82) 2.01 (0.97–2.87) 0.06 NS In labor at CS (Y/N) 1,150 (76.4) 143(12.43) 1.25 (0.89–1.76) 0.20 NS Vaginal examination (Y/N) 1,170 (77.7) 181(15.5) 1.30 (0.95–1.78) 0.10 NS Emergency CS(vs. Elective) (1158)/(416) 173(14.9)/31(7.5) 1.99(1.17–2.41) 0.004 1.76 (1.06–2.91) 0.03 General anesthesia (Y/N) (275)/(1231) 59(21.5)/145(11.8) 1.82 (0.98–1.82) 0.07 1.32 (0.98–1.77) 0.06 Preoperative skin preparation Aqueous povidone iodine (179)/(1327) 35 19.5)/169(12.7) 1.54 (0.92–2.28) 0.1 2.12 (1.41–3.19) 0.001 Iodine + alcohol 756 (50.2) 112/756 1.13 (0.82–1.56 0.45 NS Chlorhexidine + alcohol 571 (37.9) 43/572 Reference group Reference Abbreviations : BMI, Body Mass Index; RR, relative risk or risk ratio; CI, confidence interval; NS , Non-significant *Adjusted for: case-mix, (Y/N: Yes, or No, Bold values are the significant differences, with a confidence interval that does not cross 1 Discussion This prospective cohort study found a baseline incidence of surgical site infection (SSI) following cesarean section (CS) of 13.5 %( 95%CI: 11.9-15.4) among women in public hospitals in southern Ethiopia. This highlights a substantial burden of postoperative infection and is consistent with estimates from other low and middle-income countries (LMICs) and regional data from Sub-Saharan Africa [13, 22]. While comparable to pooled national estimates for Ethiopia (9.7% to 25.4%) [9] and individual study from Harer Ethiopia [23], lower than the 25.4% reported from Debretabor north Ethiopia [13]. The observed incidence varied regionally, likely reflecting differences in infection-prevention protocols, perioperative antibiotic use, and local antimicrobial resistance patterns. Importantly, this rate remains considerably higher than the <5% typically reported in high-income settings [24, 25] underscoring the need for targeted interventions. The most salient finding was that a history of prior CS was the strongest independent predictor of SSI, nearly tripling the risk compared with primary CS (aRR = 2.94, 95% CI: 2.20–3.93, p < 0.001). This is consistent with prior evidence demonstrating repeat CS as a major driver of postoperative infection [26–28]. The increased risk is mechanistically linked to adhesions and scar tissue from prior surgeries, which prolong operative time, increase tissue trauma, and impair vascular perfusion, creating a favorable environment for bacterial colonization [29, 30]. These findings underscore the need to treat repeat CS as a high-risk surgical event requiring enhanced perioperative planning and vigilant postoperative monitoring. Our analyses revealed that the effect of prior CS on SSI risk was not uniform but varied across clinical and institutional contexts. The risk was notably higher in emergency versus elective procedures, consistent with prior studies linking emergency operations to prolonged labor exposure and increased intraoperative contamination [27, 31]. Additionally, the effect was more pronounced in referral and teaching hospitals compared with primary-level facilities, likely due to referral bias, as higher-acuity institutions manage more complex cases with inherently greater surgical risk [30, 32]. Preoperative skin antisepsis was a key modifiable factor influencing SSI risk. Chlorhexidine-alcohol was associated with the lowest risk, whereas aqueous povidone-iodine (10%) associated with higher risk (aRR = 2.12, 95% CI: 1.41–3.19), aligning with evidence from randomized trials showing superior efficacy of chlorhexidine-alcohol in abdominal surgery [28, 33]. A dose-response relationship was also observed: SSI risk increased with the number of prior CS, consistent with earlier findings [30]. Beyond SSI, prior CS significantly increased intraoperative and postoperative morbidity. Women with previous CS experienced longer operative times, higher transfusion rates, more adhesions, and greater prevalence of placenta previa, reflecting the cumulative risks of multiple surgeries [16, 30]. However, other previous studies did not find the elevated requirement for blood transfusion. for example Uyanikoglu etal.(2016) [14] did not find differences in the incidence of peripartum hemorrhage and blood Transfusion in women with four or more CS compared to those with three or more. Postoperatively, these women had prolonged hospital stays and higher rates of extended antibiotic use, indicating increased resource utilization and heightened exposure to nosocomial pathogens, including multidrug-resistant organisms [34, 35].The microbiological spectrum differed between primary and repeat CS. SSIs following repeat CS were predominantly caused by Gram-negative bacilli, especially K. pneumoniae, whereas SSIs after primary CS were mainly due to Gram-positive organisms, primarily S. aureus. This shift toward Gram-negative pathogens has been reported in other LMICs and likely reflects prior healthcare exposure, antibiotic use, and contamination facilitated by intra-abdominal adhesions [36, 37]. These findings have critical implications for empirical antibiotic therapy in high-risk women. SSI after CS is multifactorial. Significant independent predictors included use of aqueous povidone-iodine (10%), priory hospitalization (aRR = 1.56), emergency CS (aRR = 1.76), and higher BMI (borderline significance). The link with recent hospitalization highlights the risk of colonization with multidrug-resistant organisms, emphasizing the need for robust infection control and context-specific antibiotic stewardship. Overall a history of prior CS significantly increases the risk of SSI and broader maternal morbidity, with effects magnified in emergency settings and modifiable through optimized skin antisepsis. The shift toward Gram-negative pathogens in repeat CS underscores the need to reconsider empirical antibiotic strategies for high-risk groups. Implications These new data are an important addition to the growing number of reports showing that repeat CS could be more complex procedure than first CS across all setting and impacting maternal health and increase surgical complexity. The findings from our study have several important implications for clinical practice and health policy in Ethiopia. First, there is a need for targeted infection prevention strategies for women undergoing repeat cesarean sections. These strategies should include the use of evidence-based preoperative antiseptic agents, such as iodine-alcohol or chlorhexidine-alcohol, to reduce the risk of infection [24, 38]. Second, given the increased risk of SSI associated with emergency procedures, efforts should be made to improve the timing and quality of cesarean sections. This includes enhancing the availability of surgical services, improving the skills of healthcare providers, and ensuring the availability of necessary surgical supplies and equipment [18]. Third, the observed differences in infection rates across different hospital tiers suggest that there may be disparities in the quality of care provided. Strengthening infection prevention and control measures, standardizing surgical protocols, and improving the infrastructure of lower-level facilities could help reduce the incidence of SSI and improve maternal outcomes [39]. Finally, the shift in the microbiological profile of SSIs underscores the need for ongoing surveillance of bacterial pathogens and antimicrobial resistance patterns. This information is crucial for developing and updating local antibiotic guidelines and for implementing effective antimicrobial stewardship programs [40]. Strengths and Limitations To the best of our knowledge, this is the first prospective cohort study with a large sample size to assess the effect of prior CS on incidence of SSIs, microbial pathogens, and other interpretative and process outcomes. The strength of the study was the prospective multicenter study design, integration of both epidemiological and microbiological data enhances understanding of pathogen-specific risks, particularly the predominance of Gram-negative organisms in repeat CS. It supports evidence-based perioperative management and antibiotic stewardship. This study also analyzed primary prospective data that used pretested, standardized data collection forms collected by well-trained research assistants to strengthen the quality of data. While the observational design of the study may introduce biases, the robust multivariable regression analysis strengthens the validity of the findings. The study's ability to control for key potential confounders enhances the reliability of the identified risk factors. Based on the large sample size analysis, the key results of the study will be generalized to the whole population of women undergoing CS in similar settings across resource-limited countries. Nevertheless, the study has limitations . First, it was conducted in a limited geographic region and three hospitals, which may affect generalizability to other settings. Second, microbiological cultures were not obtained for all SSI cases, potentially underestimating pathogen diversity and the prevalence of multidrug-resistant organisms. Third, elective CSs were underrepresented, limiting the assessment of SSI risk in this group, and women with specific comorbidities (e.g., diabetes, heart disease, or premature rupture of membranes) were excluded because of mandated postoperative antibiotics, which may have influenced the observed SSI rates. The other notable limitation of this study is the incomplete information (missed anaerobic pathogens and antimicrobial susceptibility), the effect of repeat CS on neonatal outcomes, which complicates the assessment of overall impact. Finally, all preventive measures and exposures were assessed simultaneously, limiting the ability to determine the relative contribution of each factor to SSI risk. Conclusion The study findings demonstrate that the likelihood and severity of surgical site infections (SSIs), particularly deep incisional predominantly caused by Gram-negative pathogens and increase with a prior history of cesarean section in a dose–response relationship. These risks are further amplified in emergency procedures, high-acuity hospitals, urgent surgeries, and cases with inadequate preoperative skin preparation. Women undergoing repeat CS are also at heightened risk of intraoperative complications and technical challenges, including prolonged operative time, dense adhesions, greater need for general anesthesia, and increased blood transfusion requirements. Repeat CS is additionally linked with prolonged hospital stays and extended courses of antibiotic prophylaxis. These findings highlight the critical need for robust preoperative counseling, individualized risk stratification, meticulous surgical planning, and enhanced diagnostic, surveillance, and postoperative monitoring, particularly in low-resource settings where managing complications is more difficult. Healthcare providers should be proactive in informing women of the risks associated with prior CS and prioritize limiting primary cesarean deliveries to cases with clear medical indications. This baseline data provides a foundation for future research to identify and implement effective interventions targeting high-risk subgroups, with the ultimate goal of improving maternal outcomes, surgical safety, and quality of care in LMIC settings. Declarations Ethical Considerations Ethical approval was obtained from the Institutional Review Board of Arba Minch University, College of Medicine and Health Sciences, Department of Medical Laboratory Science (IRB No. 1045/21/22). Permission letters were secured from the respective hospital managements. The study's objectives, benefits, and potential risks were clearly communicated to participants, who were informed that participation was voluntary and could be withdrawn at any time without penalty. Written informed consent was obtained from participants before the commencement of data collection. All data were de-identified and coded with a unique identifier that is linked to their identity key before starting analysis. All electronic data was kept on a password-protected computer, while all paper documents were stored in a locked file cabinet at the study centre. Only the principal investigator had access to the identity key. Microbiological analyses related to this research were provided free of charge, and positive findings were promptly communicated to treating physicians and patients for appropriate management. The study adhered to the principles outlined in the Declaration of Helsinki and complied with national and institutional ethical guidelines for research involving human subjects. Consent for publication Not applicable. This manuscript does not contain any person's data in any form (including images, videos, or clinical details). Availability of data and materials The datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding statement This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Author contribution statement Conceptualized and designed the study: SM, KT, MA, and TM Collected the data and supervision: TD, AA, and KT Performed and monitoring microbiology work; KT, KK, TD, and TM Visualization: TD, AA, KT Project management, funding acquisition, and supervision; TM, SM, and MA Formal analysis, software, and interpreted the data: KT, MA, SM, and AA Draft the Original manuscript and revise the writing: SM, KT, MA, TD Writing the final manuscript, editing, and Validation: SM, KT, AA, KK, and TD All authors reviewed and approved the final manuscript Declaration of Interests Statement The authors declare no conflict of interest. Acknowledgments The authors thank the many healthcare professionals at each participating hospital who assisted with the conduct of the surveillance, including the surveillance nurses, clinical microbiology laboratory personnel, and the physicians and nurses providing care for the patients during the study. This work would not have been possible without their cooperation and generous assistance References Mylonas I. Cesarean section: epidemiology, trends, and outcomes. American Journal of Obstetrics and Gynecology. 2011;205:11–20. https://doi.org/10.1016/j.ajog.2011.02.038. Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, et al.,. WHO systematic review of cesarean section rates. American Journal of Obstetrics and Gynecology. 2013;208:214.e1-214.e11. https://doi.org/10.1016/j.ajog.2012.12.006. Silver RM. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics & Gynecology. 2010;115:792–800. https://doi.org/10.1097/AOG.0b013e3181d04004. Tita ATN, Landon MB. Cesarean delivery: maternal complications. New England Journal of Medicine. 2016;374:1040–50. https://doi.org/10.1056/NEJMra1515243. Olsen MA, Butler AM, Willers DM, Devkota P, Fraser VJ, Dubberke ER, et al. Risk factors for surgical site infection after cesarean delivery: a systematic review. American Journal of Infection Control. 2018;46:1272–80. https://doi.org/10.1016/j.ajic.2018.02.015. Kaplanoglu M, Bulbul M, Kaplanoglu D, Bakacak SM. Effect of Multiple Repeat Cesarean Sections on Maternal Morbidity: Data from Southeast Turkey. Med Sci Monit. 2015;21:1447–53. https://doi.org/10.12659/MSM.893333. Galyean AM, Lagrew DC, Bush MC, Kurtzman JT. Previous cesarean section and the risk of postpartum maternal complications and adverse neonatal outcomes in future pregnancies. J Perinatol. 2009;29:726–30. https://doi.org/10.1038/jp.2009.108. Zuarez-Easton S, Zafran N, Garmi G, Salim R. Postcesarean wound infection: prevalence, impact, prevention, and management challenges. Int J Womens Health. 2017;9:81–8. https://doi.org/10.2147/IJWH.S98876. Mezemir R, Olayemi O, Dessie Y. Incidence and predictors of surgical site infection after cesarean section in Ethiopia. International Journal of Women’s Health. 2023;15:1547–60. https://doi.org/10.2147/IJWH.S354789. Kwee A, de Boer M, van der Veen F, al et. Surgical complexity and maternal outcomes in repeat cesarean section. Obstetrics & Gynecology. 2020;136:1235–43. https://doi.org/10.1097/AOG.0000000000004023. Surgical Site Infection (SSI) | HAI | CDC. 2021. https://www.cdc.gov/hai/ssi/ssi.html. Accessed 12 June 2022. Kasiulevičius V, Šapoka V, Filipavičiūtė R. Sample Size Calculation in Epidemiological Studies. Gerontologija. 2006;7:225–31. Bitew A, Yismaw G, Gizeyatu A, Wolde B. Prevalence of Surgical Site Infection and Associated Factors among Women Underwent Cesarean Delivery in Debretabor Town Health Institutions, Northwest Ethiopia: A Cross-Sectional Study. BMC Pregnancy and Childbirth. 2023;23:108. https://doi.org/10.1186/s12884-023-05424-9. Uyanikoglu H, Karahan MA, Turp AB, others. The Effect of the Number of Previous Cesarean Deliveries on Maternal and Perinatal Outcomes. Ginekologia Polska. 2016;87:431–5. https://doi.org/10.5603/GP.2016.0024. Alemu M, Ayana D, Tadese M, Taye B. Determinants of Surgical Site Infection after Cesarean Section in Ethiopia: A Systematic Review and Meta-Analysis. BMC Women’s Health. 2023;23:237. https://doi.org/10.1186/s12905-023-02383-3. Marshall NE, Fu R, Guise JM. Impact of Multiple Cesarean Deliveries on Maternal Morbidity: A Systematic Review. American Journal of Obstetrics and Gynecology. 2011;205:262.e1-8. https://doi.org/10.1016/j.ajog.2011.06.035. World Health Organization. Protocol for surgical site infection surveillance with a focus on settings with limited resources. Geneva: World Health Organization; 2018 Mar 31. Available from: https://www.who.int/publications/i/item/protocol-for-surgical-site-infection-surveillance-with-a-focus-on-settings-with-limited-resources Opøien HK, Valbø A, Grinde-Andersen A, Walberg M. Post-Cesarean Surgical Site Infections according to CDC Standards: Rates and Risk Factors. A Prospective Cohort Study. Acta Obstetricia et Gynecologica Scandinavica. 2007;86:1097–102. https://doi.org/10.1080/00016340701515225. Basic laboratory procedures in clinical bacteriology, 2nd ed. https://www.who.int/publications/i/item/9241545453. Accessed 27 Aug 2024. Ruan J. [Bergey’s Manual of Systematic Bacteriology (second edition) Volume 5 and the study of Actinomycetes systematic in China]. Wei Sheng Wu Xue Bao. 2013;53:521–30. Weinstein, M. P. & L JS. Clinical Laboratory Standards Institute (CLSI).Performance Standards for Antimicrobial Susceptibility Testing,. In: Clinical & Laboratory Standards Institute. 32nd Edition. USA: 940 Wayne, PA, U.S.A.; 2022. p. 362. Tsegaye S, Tsegaye Y, Tadese M, Kassa M. Surgical Site Infection and Associated Factors among Women Undergoing Cesarean Section in Ethiopia: A Systematic Review and Meta-Analysis. BMC Pregnancy and Childbirth. 2022;22:825. https://doi.org/10.1186/s12884-022-05160-6. Alemye T, Oljira L, Fekadu G, Mengesha MM. Post cesarean section surgical site infection and associated factors among women who delivered in public hospitals in Harar city, Eastern Ethiopia: A hospital-based analytic cross-sectional study. PLOS ONE. 2021;16:e0253194. https://doi.org/10.1371/journal.pone.0253194. Betrán AP, Torloni MR, Zhang J, Gülmezoglu AM, WHO Working Group on Caesarean Section. WHO Statement on Caesarean Section Rates. BJOG: An International Journal of Obstetrics & Gynaecology. 2016;123:667–70. https://doi.org/10.1111/1471-0528.13526. Owens CD, Stoessel K. Surgical Site Infections: Epidemiology, Microbiology and Prevention. The Journal of Hospital Infection. 2008;70 Suppl 2:3–10. https://doi.org/10.1016/S0195-6701(08)60017-1. Cheng Y, Cao L, Zhang Z, others. Risk Factors for Surgical Site Infection after Cesarean Delivery: A Systematic Review and Meta-Analysis. American Journal of Infection Control. 2023;51:443–51. https://doi.org/10.1016/j.ajic.2022.08.028. Wloch C, Wilson J, Lamagni T, Harrington P, Charlett A, Sheridan E. Risk Factors for Surgical Site Infection Following Caesarean Section in England: Results from a Multicentre Cohort Study. BJOG: An International Journal of Obstetrics & Gynaecology. 2012;119:1324–33. https://doi.org/10.1111/j.1471-0528.2012.03452.x. Tuuli MG, Liu J, Stout MJ, others. A Randomized Trial Comparing Skin Antiseptic Agents at Cesarean Delivery. New England Journal of Medicine. 2016;374:647–55. https://doi.org/10.1056/NEJMoa1511048. Gyamfi-Bannerman C, Srinivas SP, Wright JD, others. Postpartum Hemorrhage Outcomes and Race. American Journal of Obstetrics and Gynecology. 2023;229:675.e1-675.e18. https://doi.org/10.1016/j.ajog.2023.05.009. Silver RM. Delivery after Previous Cesarean: Long-Term Maternal Outcomes. Seminars in Perinatology. 2010;34:258–66. https://doi.org/10.1053/j.semperi.2010.03.005. Ngonzi J, Bebell LM, Fajardo Y, others. Incidence of Postpartum Infection, Outcomes and Associated Risk Factors at Mbarara Regional Referral Hospital in Uganda. BMC Pregnancy and Childbirth. 2016;16:366. https://doi.org/10.1186/s12884-016-1135-1. Gurol-Urganci I, Bou-Antoun S, Lim CP, others. Impact of Caesarean Section on Subsequent Fertility: A Systematic Review and Meta-Analysis. Human Reproduction. 2013;28:1943–52. https://doi.org/10.1093/humrep/det130. Noorani A, Rabey N, Walsh SR, Davies RJ. Systematic Review and Meta-Analysis of Preoperative Antisepsis with Chlorhexidine versus Povidone-Iodine in Clean-Contaminated Surgery. British Journal of Surgery. 2010;97:1614–20. https://doi.org/10.1002/bjs.7214. Gelaw B, Gebre-Selassie S, Tiruneh M, Mathios E, Yifru S. Isolation of Bacterial Pathogens from Patients with Postoperative Surgical Site Infections and Possible Sources of Infections at the University of Gondar Hospital, Northwest Ethiopia. Journal of Environmental and Public Health. 2023;2023:2123034. https://doi.org/10.1155/2023/2123034. Kaplanoglu M, Bulbul M, Kaplanoglu D, Bakacak SM, Tabak MS. Effect of Multiple Repeat Cesarean Sections on Maternal Morbidity and Mortality. The Journal of Maternal-Fetal & Neonatal Medicine. 2015;28:1059–63. https://doi.org/10.3109/14767058.2014.942629. Aworh MK, Oduyebo O, Nwadiaro N, others. Microbiology of Surgical Site Infections in a Tertiary Hospital in Nigeria. Journal of Global Antimicrobial Resistance. 2020;22:176–81. https://doi.org/10.1016/j.jgar.2020.02.023. Gebremariam T, Woldeamanuel GG, Asrat D, others. Microbial Etiology of Surgical Site Infections and Associated Antimicrobial Resistance Patterns in a Tertiary Hospital in Ethiopia. Infection and Drug Resistance. 2019;12:519–27. https://doi.org/10.2147/IDR.S198373. Darouiche RO, Wall MJJ, Itani KMF, others. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. New England Journal of Medicine. 2010;362:18–26. https://doi.org/10.1056/NEJMoa0810988. Betrán AP, Torloni MR, Zhang J, others. What Is the Optimal Rate of Caesarean Section at Population Level? A Systematic Review of Ecologic Studies. Reproductive Health. 2015;12:57. https://doi.org/10.1186/s12978-015-0043-6. World Health Organization. WHO Recommendations for Prevention and Treatment of Maternal Peripartum Infections. Geneva: World Health Organization; 2016. Additional Declarations No competing interests reported. Supplementary Files SupplementaryTableS1final.docx Table S1. Baseline demographic, obstetric, preoperative, and intraoperative characteristics of women undergoing first versus repeat cesarean section (n = 1,506). Cite Share Download PDF Status: Published Journal Publication published 11 Feb, 2026 Read the published version in BMC Pregnancy and Childbirth → Version 1 posted Editorial decision: Revision requested 05 Nov, 2025 Reviews received at journal 04 Nov, 2025 Reviewers agreed at journal 04 Nov, 2025 Reviewers agreed at journal 04 Nov, 2025 Reviewers agreed at journal 04 Nov, 2025 Reviewers agreed at journal 04 Nov, 2025 Reviews received at journal 28 Sep, 2025 Reviews received at journal 23 Sep, 2025 Reviewers agreed at journal 17 Sep, 2025 Reviewers agreed at journal 16 Sep, 2025 Reviewers agreed at journal 12 Sep, 2025 Reviewers agreed at journal 12 Sep, 2025 Reviewers agreed at journal 11 Sep, 2025 Reviewers invited by journal 11 Sep, 2025 Editor invited by journal 02 Sep, 2025 Editor assigned by journal 01 Sep, 2025 Submission checks completed at journal 01 Sep, 2025 First submitted to journal 31 Aug, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-7502284","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":516612997,"identity":"e7e6a5dd-6843-49b6-997c-05e773d61294","order_by":0,"name":"Mohammed Seid","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABDUlEQVRIiWNgGAWjYFACHhDBDEKGDxIM/smBuAceEKnF2OBDxQFjsJYEorQwMJhJzjhzILEBxMSnRbe99+CnGxXW9vzszBukedvupM8PO/wQaIudnG4Ddi1mZ84lS+ecSU+c2cxWYMzb9ix34+00A6CWZGOzAzi03MgxkM5tO5xgcJjHIJm3jTl34+wEkJYDidtwazH+nfvvsL09UMthoJZ0w9npHwhpMZPObTjMuIGZx7BxxpnDCfLSOQRsOXPGzDrnWHrijMNsxQwfKtIMN0jnFBxIMMDjl+M9xrdzaoAh1n94+48EAxt5+dnpmz98qLCTw6UFExiAVRoQqxwE5BtIUT0KRsEoGAUjAQAAsxlm1T5YF5IAAAAASUVORK5CYII=","orcid":"","institution":"Arba Minch University","correspondingAuthor":true,"prefix":"","firstName":"Mohammed","middleName":"","lastName":"Seid","suffix":""},{"id":516612999,"identity":"2551d0b2-9a71-4ea0-a2e0-5719eb77e714","order_by":1,"name":"Teshome Kebede²","email":"","orcid":"","institution":"Arba Minch General Hospital","correspondingAuthor":false,"prefix":"","firstName":"Teshome","middleName":"","lastName":"Kebede²","suffix":""},{"id":516613001,"identity":"adaf30cb-c09f-4c63-8524-b257775e4288","order_by":2,"name":"Aseer Manilal³","email":"","orcid":"","institution":"Komar University of Science and Technology","correspondingAuthor":false,"prefix":"","firstName":"Aseer","middleName":"","lastName":"Manilal³","suffix":""},{"id":516613002,"identity":"871c04ef-77d3-42fc-86f3-d47b51eb7de5","order_by":3,"name":"Dagimawie Tadesse","email":"","orcid":"","institution":"Global Health Institute, University of Antwerp","correspondingAuthor":false,"prefix":"","firstName":"Dagimawie","middleName":"","lastName":"Tadesse","suffix":""},{"id":516613003,"identity":"a26b0ac1-c90a-4b70-a218-8602a59495ca","order_by":4,"name":"Awol Arega","email":"","orcid":"","institution":"Arba Minch University","correspondingAuthor":false,"prefix":"","firstName":"Awol","middleName":"","lastName":"Arega","suffix":""},{"id":516613004,"identity":"876dd0bc-69ff-4744-ad55-ceffab78864d","order_by":5,"name":"Kebede Kulayta⁶","email":"","orcid":"","institution":"South Ethiopia Regional Public Health Institute, Arba Minch Public Health Laboratory","correspondingAuthor":false,"prefix":"","firstName":"Kebede","middleName":"","lastName":"Kulayta⁶","suffix":""},{"id":516613006,"identity":"30641382-f113-4043-ac44-3a8a868e3051","order_by":6,"name":"Mheret Tesfaye","email":"","orcid":"","institution":"Ethiopian Public Health Institute (EPHI)","correspondingAuthor":false,"prefix":"","firstName":"Mheret","middleName":"","lastName":"Tesfaye","suffix":""},{"id":516613007,"identity":"4ed41376-bf43-4b3f-a2bc-a8fa77ac122b","order_by":7,"name":"Dereje Tolessa","email":"","orcid":"","institution":"Arba Minch University","correspondingAuthor":false,"prefix":"","firstName":"Dereje","middleName":"","lastName":"Tolessa","suffix":""}],"badges":[],"createdAt":"2025-08-31 18:08:16","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-7502284/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-7502284/v1","draftVersion":[],"editorialEvents":[{"content":"https://doi.org/10.1186/s12884-026-08795-x","type":"published","date":"2026-02-11T15:57:29+00:00"}],"editorialNote":"","failedWorkflow":false,"files":[{"id":91843320,"identity":"dd33344f-5c49-4d76-90f3-259925d74b61","added_by":"auto","created_at":"2025-09-22 10:05:42","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":158999,"visible":true,"origin":"","legend":"","description":"","filename":"manuscriptoriginalsubmission.docx","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/1f5b0bfa35182520440041aa.docx"},{"id":91843321,"identity":"22bdb8db-bb95-4a5c-8d8c-9491cbfc9aec","added_by":"auto","created_at":"2025-09-22 10:05:42","extension":"json","order_by":1,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":10237,"visible":true,"origin":"","legend":"","description":"","filename":"074e99eecb3e488da288f6c2e3505063.json","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/dc46017738bddff6450c3b10.json"},{"id":91843325,"identity":"a6e4af15-f10d-43c6-803a-657da2d10d0b","added_by":"auto","created_at":"2025-09-22 10:05:42","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":22292,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryTableS1final.docx","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/fb22522452a5b1149299f2d7.docx"},{"id":91843327,"identity":"706336d6-9a7b-4708-a074-b5a198101d0f","added_by":"auto","created_at":"2025-09-22 10:05:42","extension":"xml","order_by":3,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":161174,"visible":true,"origin":"","legend":"","description":"","filename":"074e99eecb3e488da288f6c2e35050631enriched.xml","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/3d00b32d054879cebb9888ac.xml"},{"id":91847251,"identity":"ef0368f3-d6d4-4f75-8605-0ebc681ca286","added_by":"auto","created_at":"2025-09-22 10:21:42","extension":"png","order_by":5,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":32151,"visible":true,"origin":"","legend":"","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/83b7cdcf260326e28c19646b.png"},{"id":91843322,"identity":"369c221b-5319-4ba4-83be-8c0e1f0287c4","added_by":"auto","created_at":"2025-09-22 10:05:42","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":13890,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/8f79dac42f01f5a07b7aaee5.png"},{"id":91843328,"identity":"34954dfc-3042-4b37-be6a-e6eacbcd2c78","added_by":"auto","created_at":"2025-09-22 10:05:42","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":153846,"visible":true,"origin":"","legend":"","description":"","filename":"074e99eecb3e488da288f6c2e35050631structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/3eef8ae66a5cc7bed64893f5.xml"},{"id":91843326,"identity":"33c35346-4944-403e-8556-5bd3f220b12b","added_by":"auto","created_at":"2025-09-22 10:05:42","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":172161,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/21e0bcd3c196f4f2b8d7af70.html"},{"id":91845728,"identity":"a7498255-7435-4d2a-932a-bcfcbc86819b","added_by":"auto","created_at":"2025-09-22 10:13:42","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":32151,"visible":true,"origin":"","legend":"\u003cp\u003eFlow diagram of participant enrollment and follow-Up\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/982f7550cd83d4440ce11942.png"},{"id":91843318,"identity":"ab200a70-97b0-43ff-b5f5-e8626274de53","added_by":"auto","created_at":"2025-09-22 10:05:42","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58135,"visible":true,"origin":"","legend":"\u003cp\u003eMicrobial profile of CS-SSI after CS by the number of priory CS delivery (first CS vs repeat CS) at three hospitals in the south Ethiopia regional states (n=211)\u003c/p\u003e\n\u003cp\u003e\u003cem\u003e\u003cstrong\u003eAbbreviations:\u003c/strong\u003e\u003c/em\u003e\u003cem\u003eCoNS; Coagulase-negative Staphylococci\u003c/em\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/daa0ab25b6bc68671830ff80.png"},{"id":102785411,"identity":"8c7bea6b-19d5-4677-9129-04a024e48670","added_by":"auto","created_at":"2026-02-16 16:06:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1935283,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/ef823d09-76f9-44cc-91a9-8d1d6b710dd9.pdf"},{"id":91845729,"identity":"94bfabbd-3a3f-4343-a872-b645c4070e48","added_by":"auto","created_at":"2025-09-22 10:13:42","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":22292,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTable S1. Baseline demographic, obstetric, preoperative, and intraoperative characteristics of women undergoing first versus repeat cesarean section (n = 1,506).\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"SupplementaryTableS1final.docx","url":"https://assets-eu.researchsquare.com/files/rs-7502284/v1/d64a4c5c7aac20c6b1bea36c.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"\u003cp\u003eImpact of Prior Cesarean Section on Surgical Site Infections, Microbiological patterns, and Surgical Outcomes: A Prospective Multicenter Cohort Study in South Ethiopia\u003c/p\u003e","fulltext":[{"header":"Introduction","content":"\u003cp\u003eCesarean section (CS) is a fundamental surgical intervention in obstetrics, critical for reducing maternal and perinatal mortality in complicated pregnancies [\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e]. Originally reserved for life-saving indications, CS use has expanded worldwide due to factors such as perceived safety, convenience, and medico-legal pressures [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. Consequently, global CS rates have more than doubled over the past 25 years, reaching 21.1%, well above the World Health Organization\u0026rsquo;s recommended rate of 10\u0026ndash;15% [\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e]. A major contributor to this trend is the rising number of repeat cesarean deliveries (RCDs), which account for 15\u0026ndash;68% of all procedures[\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eWhile CS is life-saving, it carries substantially higher risks than vaginal delivery. It is the single most important risk factor for postpartum infection, with surgical site infections (SSIs), endometritis, and urinary tract infections being the most common [\u003cspan additionalcitationids=\"CR5\" citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. SSIs lead to prolonged hospitalization, increased healthcare costs, higher antibiotic use, and long-term sequelae including chronic pelvic pain, secondary infertility, and wound dehiscence [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eIn low- and middle-income countries (LMICs) such as Ethiopia, post-CS SSI incidence ranges from 9.7\u0026ndash;25.4%, placing additional strain on already fragile health systems [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eThe risk of maternal complications increases substantially with a history of prior CS. Previous CS is consistently identified as a strong independent risk factor for postoperative morbidity, nearly tripling the risk of infection due to altered tissue planes, adhesions, and longer operative times [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e]. Repeat CS is also associated with greater surgical complexity, including adhesiolysis, increased blood loss, and longer operative time, which heightens intraoperative and postoperative complications [\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e]. Furthermore, the microbiological profile of SSIs is evolving in LMICs, with multidrug-resistant Gram-negative pathogens, particularly \u003cem\u003eEscherichia coli\u003c/em\u003e and \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e, increasingly complicating management [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e, \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eDespite the growing prevalence of repeat CS and associated maternal risks, robust prospective data comparing primary and repeat CS outcomes in Ethiopia remain scarce. Most existing studies are retrospective or single-center, limiting their generalizability [\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e]. Moreover, few studies provide detailed microbiological characterization of SSIs or explore modifiable risk factors in this context [\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e].\u003c/p\u003e\u003cp\u003eAddressing this gap, the present prospective cohort study aims to assess the impact of prior CS on maternal complications, with a primary focus on 30-day SSI incidence. Secondary objectives include evaluating severity, microbiological profiles, intraoperative challenges, such as prevalence of adhesions, operative time, anesthesia type, and blood transfusion; and postoperative outcomes, such as hospital stay, continued antibiotic use, and readmission. Subgroup analyses will explore the influence of key patient mix factors on SSI risk. Key findings of this study will inform targeted infection prevention, antibiotic stewardship, and surgical planning to reduce maternal morbidity in Ethiopia and comparable LMIC settings\u003c/p\u003e"},{"header":"Materials and methods","content":"\u003ch2\u003eStudy design, setting, and durations\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThis prospective cohort study was conducted between January and December 2022 across three purposively selected government hospitals located within the South Ethiopian Regional State. \u0026nbsp;These are Gidole Primary Hospital in Gardula Zone, Arba Minch General Hospital in Gamo Zone, and Wolayita Sodo University Comprehensive Specialized Hospital (WSUCSH) in Wolayita Zone. These zones were selected based on their geographic proximity, population characteristics, and healthcare infrastructure, facilitating efficient data collection and follow-up. Hospital volume was defined as the mean annual number of CS procedures between 2021 and 2022, and hospitals were selected using three key criteria: (1) their level within Ethiopia\u0026apos;s healthcare hierarchy, (2) an annual CS volume, and (3) geographic representation. The selection of hospitals in this study was based on a tiered selection approach, which included primary hospitals, general hospitals, and teaching and referral hospitals.\u0026nbsp;\u003c/p\u003e\n\u003ch2\u003ePopulations\u003c/h2\u003e\n\u003cp\u003eThe target population for this study comprised women with singleton pregnancies who underwent cesarean section (CS) at the participating hospitals and delivered at term.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe study population comprised all women \u0026gt;18 years of age admitted for elective or emergency CS at labor and obstetric wards during the study period in the selected hospitals and fulfilled the eligibility criteria. The study population in the study cohort was defined based on the primary exposure or factor variable (number of prior CS).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExposure cohort\u003c/strong\u003e or study group: Multiparous pregnant women who had a history of previous CS and were further stratified as repeat CS (one or two previous CS) and multiple repeat (\u0026ge;3 prior CS). The comparator cohort (C) comprised all women with first-time CS (primary CS); this group was used as a baseline comparison to contextualize the maternal morbidity associated with repeat CS.\u003cstrong\u003e\u0026nbsp;Figure\u003c/strong\u003e 1 displays the population flow chart of subjects and exclusion criteria in the present analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEligibility criteria\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eInclusion criteria\u0026nbsp;\u003c/strong\u003e(both exposed and comparison cohorts): Women were eligible if they were aged 18 years or older, had a singleton pregnancy, attended the obstetric ward and labor room, underwent elective or emergency CS (for any indications), provided written informed consent (surrogate consent), and resided within the follow-up area or were reachable by phone during postoperative follow-up of at least 30 days [11].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExclusion criteria:\u0026nbsp;\u003c/strong\u003eWomen were excluded if they had an active infection at the time of surgery, including clinical sepsis, chorioamnionitis (fever, fetal tachycardia, increased HSCRP, uterine tenderness, foul-smelling discharge), or an unresolved surgical wound infection from a prior operation. Additionally, women referred after undergoing CS at another facility and women who had concurrent surgery were excluded due to incomplete preoperative and intraoperative data. Cases with missing or incomplete medical records, as well as participants, who could not be followed for the whole 30-day surveillance period because of relocation, incorrect contact information, or voluntary withdrawal, were also excluded. Women who were critically ill or had a major psychiatric illness were excluded.\u003c/p\u003e\n\u003ch2\u003eSample size and sampling techniques\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThe sample size was calculated using the two-population proportion formula [12] \u0026nbsp;in OpenEpi. In this calculation, \u003cem\u003ep₁\u003c/em\u003e represented the incidence of SSI in the baseline population and \u003cem\u003ep₂\u003c/em\u003e the incidence among women with a prior cesarean section. We assumed a significance level of 5% (Z\u0026alpha; = 1.96) and a power of 80% (Z\u0026beta; = 0.84). A baseline incidence of SSI following cesarean section was taken as 11% [9]. Previous studies have reported that repeat cesarean delivery increases the risk of SSI by 1.2\u0026ndash;2-fold [5, 13, 14]. For this study, we planned to detect an increase of 1.47 (i.e., from 11% to 16.2% as a clinically meaningful estimate within that reported range). With a 1:1 ratio of exposed to non-exposed groups, the minimum required sample size was 1,376 women (688 per group). To account for potential loss to follow-up or incomplete data, a 10% contingency was added, yielding a final required sample size of 1,514 participants (757 per group). However, during the one-year study period, the total participants enrolled in the study were n = 1,506 (a total of 753 per group).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample allocation and sampling procedure\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe final study sample comprised 1,506 women, equally divided into two groups: 753 undergoing their first cesarean section (primary CS group, controls) and 753 with one or more prior cesarean deliveries (repeat CS group, exposed). A 1:1 ratio was maintained to allow balanced statistical comparisons between groups. To ensure representativeness across the regional healthcare system, the sample was proportionally allocated to the three participating hospitals according to their annual cesarean delivery volume. Based on this approach, the final sampled participants by hospitals were: Gidole Primary Hospital (annual volume 460) contributed 211 participants, Arba Minch General Hospital (annual volume 1,043) contributed 477 participants, and Wolayita Sodo University Comprehensive Specialized Hospital (annual volume 2,084) contributed 818 participants. Within each hospital, participants were selected using stratified systematic sampling techniques. Within each stratum defined by hospital and CS type, systematic random sampling was applied. The sampling frame was prepared using the previous year\u0026rsquo;s cesarean section records from each hospital to estimate the number and flow of eligible women during the study period. Based on this, the total number of eligible women for each hospital was determined, and the hospital-specific sample size was allocated proportionally. A systematic sampling approach was then employed: the sampling interval (\u003cem\u003ek\u003c/em\u003e) was calculated by dividing the total number of eligible women by the allocated sample size. The first participant was randomly selected using a lottery method, and every \u003cem\u003ek\u003c/em\u003eth eligible woman thereafter was enrolled until the required sample size was reached. If a selected participant was ineligible or declined participation, the subsequent \u003cem\u003ek\u003c/em\u003e-th eligible woman was included, ensuring unbiased selection without replacement (see participant flow chart\u003cstrong\u003e, Figure 1).\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eStudy variables (exposure, outcome, and covariates)\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary exposure/factor variables assessment\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary exposure of interest in this study was a previous history of cesarean section (CS). This variable was defined as whether a woman had undergone one or more CS deliveries prior to the index operation during the study period. Information on prior CS history was obtained from medical records and confirmed through participant interviews at enrollment. For analysis, exposure was categorized into two groups: the exposed group, women with a documented prior history of at least one previous CS, and the unexposed group, women undergoing their first CS (no previous history of CS). For subgroup and sensitivity analyses, the number of prior CS deliveries (one, two, or \u0026ge; three) was also recorded to explore the possibility of a dose-response relationship between repeated cesareans and maternal complications.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePrimary and secondary outcomes\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe primary outcome was SSI diagnosis within 30\u0026nbsp;days of CS delivery. SSI diagnosis was based on criteria aligned with the recommendations of the National Healthcare Safety Network of the Centre for Disease Control and Prevention (CDC) [11]. The treating clinician or gynecologist made diagnoses through review of patients\u0026apos; charts, medical records, and microbiological data, and the investigator subsequently verified these. The outcome was recorded as a binary variable (present/absent). The primary metric was the cumulative incidence proportion (risk) of SSI among women with a prior cesarean section who underwent CS during the study period, expressed as a percentage with 95% confidence intervals (CI). Secondary outcomes were the type of SSI (superficial incisional vs. deep incisional. The other pre-specified secondary outcomes included the intraoperative events such as duration of surgery, intraoperative blood transfusion, prevalence of intra-abdominal adhesion, placental previa, and others in the postoperative phase; culture positivity of wound samples, microbial profile of SSI, length of hospital stay, postoperative antibiotic use, re-admission to hospital, and mortality. A secondary outcome also included risk factors for SSI after CS [15]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCovariates/risk factors and potential confounders\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePotential covariates considered in the analysis were grouped into demographic, obstetric/clinical, and operational/procedural factors. Demographic factors were age group (\u0026lt;20, 20\u0026ndash;29, \u0026gt;30 years), residence (urban or rural), body mass index, alcohol, and tobacco use. Obstetric and clinical factors comprised parity status (primiparous, multiparous, or grand multiparous), referral status (yes/no), antenatal complications such as labor before CS, duration of labor (in hours), presence of membrane rupture before CS and durations, vaginal examinations (yes/no), number of vaginal examinations, history of hospitalization (90 days) (yes/no), and underlying medical conditions (presence, number, and type). Procedure-related factors were urgency (emergency vs. elective CS) and type of incision (Pfannenstiel(Transverse) vs. vertical midline), intraoperative events such as blood transfusion (yes/no), surgical hand scrub method (plain soap and water vs. antiseptic hand rub), preoperative skin preparation (aqueous povidone-iodine (10%), iodine + alcohol vs. chlorhexidine alcohol), skin closure type (interrupted vs. other), duration of operation (min), grade of surgeon, surgical antibiotic prophylaxis use (type, timing, and dose), and use of anesthesia (general vs. spinal). These covariates were selected based on clinical relevance and potential to confound the association between cesarean section type and surgical site infection.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eOperational definitions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe presence of pre-existing medical conditions\u003c/strong\u003e was defined as the presence or absence of any of the following: hypertension, anemia, diabetes mellitus, malaria or acute febrile illness, or the presence of any chronic systemic disease like HIV, renal disease, heart disease, or liver disease. [24]\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eRepeat caesarean section (CS)\u003c/strong\u003e was defined as any caesarean delivery performed in a woman who has had at least one previous CS [3] and \u003cstrong\u003eMultiple repeat CS was defined as\u0026nbsp;\u003c/strong\u003ethree or more previous CS deliveries [16].\u003c/p\u003e\n\u003ch2\u003eStudy procedures\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003e\u003cstrong\u003eEnrollment, Consenting \u0026amp; Follow-up\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eParticipants were enrolled preoperatively (at admission to the obstetrics ward and labor room) following written informed consent, and the eligibility criteria were fulfilled and followed for 30 days post CS delivery. All eligible women scheduled for cesarean section (CS) delivery during the study period were consecutively approached for enrollment. Recruitment was carried out in the obstetrics and gynecology ward by trained research nurses who worked in close collaboration with the clinical care team to identify potential participants before surgery. Women were approached in the preoperative period, provided with a brief explanation of the study objectives, procedures, risks, and potential benefits, and were given adequate time to ask questions. Written informed consent was obtained from each participant prior to enrollment. For women who could not read or write, the consent form was read aloud in the local language by a trained staff member, and a literate witness not directly involved in the study confirmed the participant\u0026rsquo;s decision by signing the consent document. Participants were assured that their decision to take part or not would not affect their medical care in any way. Confidentiality of personal and clinical information was strictly maintained by using unique study identifiers and restricting data access to authorized study personnel only. Enrolled women were followed from the time of the index CS through 30 days post-operation to monitor for surgical site infection (SSI) and other maternal complications. Follow-up was conducted through daily ward visits during admission, review of hospital records, and scheduled outpatient or telephone follow-up after discharge. The enrollment strategy aimed to include all eligible participants within a fixed period, as recommended by the WHO [17]. However, due to logistical and feasibility concerns, a total of 1506 participants were systematically selected and enrolled into either the exposure or comparison cohort in a 1:1 ratio. For each repeat CS, the first time CS was enrolled. Enrollment occurred at the time of observation and included days, nights, and weekends. Each eligible consented participant was assigned a unique study identification number, and all baseline and follow-up data were collected using a pretested tool.\u003c/p\u003e\n\u003ch3\u003eData collection procedures\u003c/h3\u003e\n\u003cp\u003e\u003cstrong\u003eData source, collection tools, and methods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEssential data were collected before and during surgery, using information obtained directly from patients, operation notes, anesthesia records, medical and medication charts, and direct observations. Data were collected prospectively from women who underwent cesarean section at three public hospitals in southern Ethiopia through physical or clinical examinations, structured interviews (socio-demographics, behavioral and obstetric history), and hospital record reviews (clinical, laboratory, and operation-related data). A semi-structured questionnaire, case report form, data abstraction form, and a standardized SSI checklist were developed after reviewing literature and guidelines [17, 18] and pretested and used to collect socio-demographic, behavioral, obstetric, clinical, and operation-related data (preoperative, intraoperative, and postoperative) from patient interviews and medical records. Data were collected by trained research assistants (an obstetrician, a gynecologist, a midwifery nurse, and a medical microbiologist) after written informed consent was obtained.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eBaseline data collection procedures\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData were collected using a structured case report form (CRF) developed specifically for the study. The Case report form (CRF) was pretested on a small group of participants to ensure clarity and completeness, and minor modifications were made before use in the main study. Data collection was carried out by trained research nurses and midwives who were not part of the surgical team to minimize observer bias. Baseline data were obtained preoperatively through direct interview and review of medical records. This included socio-demographic information (age, residence, educational status, occupation), obstetric history (gravidity, parity, history of previous cesarean delivery, antenatal care attendance), existing medical history (diabetes mellitus, hypertension, HIV status), and indication for the current CS.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSurgery related data collections\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThese included type of cesarean section (elective or emergency), duration of surgery, blood loss, type of anesthesia, surgeon\u0026rsquo;s level of experience, use of surgical antimicrobial prophylaxis, and intraoperative complications. All women enrolled in the study were followed for 30 days after cesarean delivery to ascertain the occurrence of surgical site infections (SSIs) and other postoperative complications. Follow-up began on the day of the operation (day 0) and continued until the end of the 30-day period or until the patient was lost to follow-up.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIn-hospital follow-up:\u0026nbsp;\u003c/strong\u003eDuring the immediate postoperative period, daily clinical assessments were conducted by trained research nurses until discharge. Data on vital signs, wound appearance, pain, fever, antibiotic administration, and other maternal outcomes were documented. Any suspected infection was evaluated in collaboration with the attending physician, and wound swabs were collected for microbiological analysis where indicated.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003ePost-discharge follow-up:\u0026nbsp;\u003c/strong\u003eAfter discharge, women were actively followed up through a combination of scheduled outpatient clinic visits (typically on postoperative days 7, 14, and 30) and telephone follow-up as per the protocol\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConfirmation of outcomes: S\u003c/strong\u003eSSIs were defined and classified according to the Centers for Disease Control and Prevention (CDC) criteria (superficial incisional, deep incisional, or organ/space). For each suspected case, a standardized assessment checklist was applied. Microbiological confirmation was sought whenever possible.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFollow-up completeness and retention strategies:\u0026nbsp;\u003c/strong\u003eTo minimize loss to follow-up, detailed contact information was collected at enrollment, including mobile phone numbers of participants and close relatives. Reminder calls were made before scheduled visits, and transportation reimbursement was provided where necessary. If participants could not attend the clinic, assessments were made via structured phone interviews, and if infection was suspected, arrangements were made for facility-based evaluation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMicrobiological methods\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eSample collection, transport, and processing:\u0026nbsp;\u003c/strong\u003eClinical specimens (wound swabs and aspirates)\u0026nbsp;were collected aseptically from women presenting with signs of post-operative infection following CS by trained health care personnel (microbiologist, midwifery nurse, or clinicians/ obstetricians aseptically following standard protocol and procedures[17]. All specimens were promptly transported to the microbiology laboratory under appropriate temperature-controlled conditions maintain viability. Culture and isolation of bacteria were performed through conventional culture and biochemical test following the standard microbiological techniques [19]. Upon receipt, each specimen was inoculated onto 5% sheep blood agar, MacConkey agar, mannitol salt agar, and chocolate agar and the first two were incubated aerobically at 35\u0026ndash;37\u0026deg;C for 24\u0026ndash;48 hours, whereas chocolate agar plates were incubated with 5-10% CO₂ using a candle jar alongside other plates for 24\u0026ndash;48 hours at 35\u0026ndash;37\u0026deg;C [19].\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eIdentification of Isolates\u003c/strong\u003e\u0026mdash;Bacterial isolates were identified using conventional culture techniques and battery of standard biochemical assays. Colony morphology, hemolysis, pigmentation, and Gram stain were used for preliminary differentiation of isolates. Identification of Gram-positive cocci was carried out using catalase and coagulase tests for \u003cem\u003eStaphylococcus aureus\u003c/em\u003e, and bile esculin hydrolysis, and salt tolerance test for \u003cem\u003eEnterococcus\u003c/em\u003e species. Gram-negative bacilli were identified through a panel of conventional biochemical tests including oxidase, triple sugar iron (TSI) agar, IMVIC ((Indole, Methyl Red, Voges\u0026ndash;Proskauer, Citrate utilization), urease, motility, and hydrogen sulfide production, and carbohydrate fermentation tests. Species identifications and interpretation of test results were according to Bergey\u0026apos;s Manual of Systematic Bacteriology [20]. Laboratory findings were systematically recorded and linked with clinical data to confirm infection status.\u003c/p\u003e\n\u003ch2\u003eQuality assurance\u003c/h2\u003e\n\u003cp\u003eTo ensure data quality, comprehensive training was provided before study initiation on data collection tools, surveillance methods (including participant recruitment, consent procedures, and follow-up), data recording, and microbiological techniques. A pretest was conducted on 5% of the sample at Chencha Hospital, which was not part of the main study. The questionnaire was initially developed in English, translated into the local language, and then back-translated to English to ensure accuracy. Laboratory test reliability was maintained through rigorous quality control measures, including the use of reference strains \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (ATCC 27853) and \u003cem\u003eEscherichia coli\u003c/em\u003e (ATCC 25922) procured from the Ethiopian Public Health Institute (EPHI). The principal investigator conducted daily quality control check and sterility and performance of culture media were checked for each batch.\u0026nbsp;Data checks for completeness, clarity, and consistency, and standard operating protocols were strictly followed for all laboratory procedures [21].\u003c/p\u003e\n\u003ch2\u003eData management and statistical analysis\u003c/h2\u003e\n\u003cp\u003eData were entered into EpiData (CDC, USA) and exported to SPSS version 25.0 (IBM Corp., Chicago, IL) for analysis. Baseline characteristics were summarized using descriptive statistics: categorical variables were presented as frequencies and percentages, and continuous variables as means with standard deviations (\u0026plusmn;SD) or medians with interquartile ranges (IQR), depending on data distribution. The Shapiro\u0026ndash;Wilk test was used to assess normality of continuous variables. Group comparisons were performed using the independent t-test for normally distributed variables and the Wilcoxon rank-sum test for non-normally distributed variables. Categorical variables were compared using the chi-square (\u0026chi;\u0026sup2;) test or Fisher\u0026rsquo;s exact test, as appropriate.\u003c/p\u003e\n\u003cp\u003eComparisons were first made between women with prior cesarean section (repeat CS) and those undergoing first-time CS on baseline socio-demographic and obstetric characteristics. Case-mix factors considered included socio-demographic characteristics (age, residence), medical and obstetric factors (body mass index [BMI], comorbidities, prior hospitalizations, rupture of membranes, antenatal care attendance, labor characteristics), history of prior CS, operative-related factors (urgency, duration, infection prevention practice), and environmental factors (hospital type). Subgroup analyses of the primary outcome (surgical site infection, SSI) were performed by hospital type, urgency of CS (elective vs. emergency), obesity status (BMI \u0026lt;30 vs. \u0026ge;30), prolonged rupture of membranes (\u0026gt;18 h), presence of pre-existing medical conditions, and type of preoperative skin preparation (povidone iodine, iodine + alcohol, or chlorhexidine\u0026ndash;alcohol). To identify risk factors for SSI, Poisson regression with robust variance estimators was used to estimate relative risks (RRs) and adjusted relative risks (aRRs) with 95% confidence intervals (CIs). SSI was modeled as a binary outcome, with the number of prior CS (first CS vs. repeat CS) as the primary exposure of interest. Potential confounders were identified based on prior literature and biological plausibility, and included demographic, obstetric/clinical, and procedural variables. Demographic variables included age group (\u0026lt;20, 20\u0026ndash;29, \u0026gt;30 years), residence (urban vs. rural), education level, obesity status (BMI \u0026lt;30 vs. \u0026ge;30), alcohol use, and smoking. Obstetric and clinical factors included parity, referral status, labor before CS, prolonged labor (\u0026gt;24 h), rupture of membranes, prior hospitalization, comorbidities (HIV, hypertension, diabetes, and anemia), emergency CS, and type of incision. Procedural and operational factors included number of vaginal examinations, intraoperative transfusion, surgical hand scrub method, preoperative skin preparation, skin closure type, antibiotic prophylaxis, and anesthesia type. Covariates were first assessed in bivariate analyses and those with a p-value \u0026lt;0.20 were considered for inclusion in multivariable models. The final adjusted Poisson regression model included type of CS and all significant covariates. Two-sided p-values \u0026lt;0.05 were considered statistically significant\u003c/p\u003e"},{"header":"Results","content":"\u003ch2\u003eStudy participant flow in the study\u003c/h2\u003e\n\u003cp\u003eDuring the study period, a total of 3,587 women undergoing cesarean section were assessed for eligibility across three hospitals: Gidole Primary Hospital (n = 460), Arba Minch General Hospital (n = 1,043), and Wolayita Sodo University Comprehensive Specialized Hospital (n = 2,084). Of these, 102 were excluded (9 from Gidole, 37 from Arba Minch, and 56 from Wolayita Sodo), resulting in 3,485 eligible women. From the eligible population, 1,506 participants were enrolled using proportional allocation and systematic random sampling, with equal distribution between women undergoing their first cesarean section (n = 753) and those with a prior history of CS (n = 753). The allocation by hospital was as follows: first CS\u0026mdash;128 at Gidole, 238 at Arba Minch, and 387 at Wolayita Sodo; women with prior history of CS (repeat CS group)=83 at Gidole, 239 at Arba Minch, and 431 at Wolayita Sodo. All enrolled women were followed for 30 days after surgery, including 211 from Gidole, 477 from Arba Minch, and 818 from Wolayita Sodo. The primary outcome, surgical site infection, was documented in 204 participants, of whom 181 had microbiologically confirmed infections (Figure 1).\u003c/p\u003e\n\u003ch2\u003eBaseline characteristics of the study participants\u003c/h2\u003e\n\u003cp\u003eAt baseline, the two cohorts were broadly comparable in socio-demographic characteristics \u003cstrong\u003e(TableS1).\u003c/strong\u003e Women undergoing repeat CS were older on average than those with a first CS (30.1 \u0026plusmn; 5.6 vs. 26.9 \u0026plusmn; 5.0 years, \u003cem\u003ep\u0026lt;0.001\u003c/em\u003e), though age-category distributions (\u0026lt;30 vs. \u0026ge;30 years) were similar (p=0.998). Residence and education were evenly distributed across groups, with nearly half residing in urban areas and over one-third having attained college-level education. Mean BMI was slightly higher in the repeat CS group (25.9 \u0026plusmn; 4.3 vs. 24.8 \u0026plusmn; 3.7, \u003cem\u003ep\u0026lt;0.001\u003c/em\u003e), but obesity prevalence was identical (4.9%). In contrast, obstetric and clinical profiles differed. Referrals were more frequent among repeat CS women (42.4% vs. 34.5%, \u003cem\u003ep=0.002\u003c/em\u003e). As expected, parity distributions diverged significantly, with most first CS cases being primiparous and most repeat CS cases multiparous or grand multiparous \u003cem\u003e(p\u0026lt;0.001).\u003c/em\u003e ANC attendance was high overall, though \u0026ge;4 visits were more common in first CS (75.2% vs. 58.8%, \u003cem\u003ep\u0026lt;0.001\u003c/em\u003e). At presentation, first CS cases were more often in labor (79.7% vs. 73.0%, \u003cem\u003ep=0.003\u003c/em\u003e), while prolonged labor and prior hospitalization were more common in repeat CS (both \u003cem\u003ep\u0026lt;0.05\u003c/em\u003e). Membrane rupture before surgery (65.1% vs. 46.5%) and multiple vaginal examinations (86.4% vs. 69.1%) were also more frequent in repeat CS \u003cem\u003e(p\u0026lt;0.001).\u003c/em\u003ePre-existing medical conditions were reported at similar rates across groups, with no significant differences in hypertension, anemia, HIV, diabetes, hepatitis B, or malaria. Intraoperative, emergency CS predominated in first CS (88.7% vs. 65.1%, \u003cem\u003ep\u0026lt;0.001),\u003c/em\u003e while elective procedures were more common in repeat CS (34.9% vs. 11.3%). General anesthesia was used more frequently in repeat CS (20.6% vs. 15.9%, \u003cem\u003ep=0.030\u003c/em\u003e). Skin preparation practices differed, with alcohol + iodine more common in repeat CS and chlorhexidine + alcohol in first CS (both \u003cem\u003ep\u0026lt;0.001\u003c/em\u003e). Surgical antibiotic prophylaxis use was nearly universal in both groups (\u0026gt;97%). Detailed baseline characteristics are provided in the additional file \u003cstrong\u003e(Supplementary Tables S1)\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eIncidence of Post-CS Surgical Site Infections (SSIs)\u003c/h2\u003e\n\u003cp\u003eAmong the 1,506 women who underwent CS, the overall cumulative incidence of surgical site infection (SSI) was 13.5% (204/1,506; 95% CI: 11.9\u0026ndash;15.4) after a mean follow-up of 13.7 \u0026plusmn; 2.9 days. SSI risk was significantly higher in women with a prior CS compared to first-time CS (20.3% vs. 6.8%), corresponding to a relative risk (RR) of 2.98 (95% CI: 2.20\u0026ndash;4.03) and a risk difference (RD) of 13.5% (95% CI: 10.1\u0026ndash;16.9%; \u003cem\u003ep \u0026lt; 0.001).\u0026nbsp;\u003c/em\u003eSuperficial incisional infections accounted for 75.0% of all SSIs, while deep incisional SSI accounted for 25.0%. Deep incisional SSI was more frequent in the repeat CS group (30.1%) than in the first CS group (9.8%) (RR: 3.07; 95% CI: 1.28\u0026ndash;7.36; RD: 20.3%; 95% CI: 9.4\u0026ndash;31.2%; \u003cem\u003ep = 0.012\u003c/em\u003e). The timing of SSI early (before discharge) versus post-discharge\u0026mdash;was similar between groups (early: 37.9% vs. 37.3%, RR 1.02, 95% CI: 0.66\u0026ndash;1.58; p = 0.870; post-discharge: 62.1% vs. 62.7%, RR 0.99, 95% CI: 0.74\u0026ndash;1.34; \u003cem\u003ep = 0.940\u003c/em\u003e). The mean time to SSI onset was significantly longer in repeat CS women (15.9 \u0026plusmn; 2.9 days) compared to first CS women (7.1 \u0026plusmn; 2.9 days; \u003cem\u003ep \u0026lt; 0.001\u003c/em\u003e). Of the 204 wound samples, 88.7% (181/204) were culture-positive, yielding 211 bacterial isolates. Monobacterial infections predominated (83.4%), with Gram-negative bacteria accounting for 79.6% of isolates. Gram-negative infections were more frequent in repeat CS women (83.8% vs. 68.6%; RR: 1.22, 95% CI: 1.00\u0026ndash;1.49; \u003cem\u003ep = 0.027\u003c/em\u003e). Gram-positive isolates were detected in 37.0% of cases, more commonly among first CS women (45.1% vs. 33.8%; \u003cem\u003ep = 0.127\u003c/em\u003e). Mixed Gram-negative and Gram-positive infections were uncommon (12.7%). Superficial SSIs were less frequent in repeat CS women (69.9%) than first CS women (90.2%) (RR: 0.78; 95% CI: 0.66\u0026ndash;0.91; \u003cem\u003ep = 0.002\u003c/em\u003e), whereas deep incisional SSI was more frequent in repeat CS women (30.1% vs. 9.8%; RR: 3.07; 95% CI: 1.28\u0026ndash;7.36; \u003cem\u003ep = 0.012).\u003c/em\u003e Surveillance indicated that 40.7% of SSIs were identified before discharge and 59.3% after discharge, with no significant differences between groups (p \u0026gt; 0.05). Detailed microbiological patterns are summarized in \u003cstrong\u003eTable 1.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003e1\u003c/strong\u003e\u003cstrong\u003e:\u003c/strong\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003eIncidence of SSIs by type of CS (first CS vs. women with prior history of CS\u003cstrong\u003e\u0026nbsp;(\u003c/strong\u003erepeat CS cohort) in a cohort of 1506 women who underwent CS delivery at three selected hospitals\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"877\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eOutcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 216px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eComparison group\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRelative risk (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRisk difference (95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"3\" valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePriory CS (\u0026ge;1)\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n=753)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFirst CS (n=753)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAny SSI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e204 (13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e153 (20.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e51 (6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e2.98 \u003cstrong\u003e(2.20\u0026ndash;4.03)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e13.5 (10.1\u0026ndash;16.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 877px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDepth and severity of SS after CS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eSuperficial\u0026nbsp;SSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e153(75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e107 (69.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e46 (90.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.78 \u003cstrong\u003e( 0.66-0.91)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eDeep incisional\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e51 (25)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e46(30.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e5(9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e3.07 \u003cstrong\u003e(\u003c/strong\u003e1.28-7.36\u003cstrong\u003e)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e20.3 (9.4\u0026ndash;31.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.012\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eTime to onset( X \u0026plusmn; SD)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e13.7 \u0026plusmn; 2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e15.9 \u0026plusmn; 2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e7.1 \u0026plusmn; 2.9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\u003cbr\u003e\u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 613px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eDistribution of early vs. late SSI\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eSSI before discharge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e83 (40.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e58 (37.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e19 (37.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.02 (0.66\u0026ndash;1.58)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.870\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eSSI post-discharge\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e121 (59.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e95 (62.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e32 (62.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.99 (0.74\u0026ndash;1.34)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.940\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"7\" valign=\"top\" style=\"width: 877px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eMicrobiological findings\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eCulture confirmed SSI\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e181/204\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e153(85.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e51(100.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.85(\u003cstrong\u003e0.78-0.92)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026minus;15.0 (\u0026minus;20.2 to \u0026minus;9.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eMonobacterial infection\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e151 (83.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e109 (83.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e42(82.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.02(0.87-1.19)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.82\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eGram negative bacteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e106 (58.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e81 (74.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e35(68.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.22 (1.00-1.49)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e5.7 ( \u0026minus;9.4 to 20.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.027\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003eGram positive bacteria\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e45 (24.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e28 (25.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e23(45.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.75 (0.51-1.11)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.127\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 187px;\"\u003e\n \u003cp\u003ePolymicrobial infections\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 84px;\"\u003e\n \u003cp\u003e30 (16.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e21 (16.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 90px;\"\u003e\n \u003cp\u003e9(17.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e0.92 (0.45-1.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 162px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 102px;\"\u003e\n \u003cp\u003e0.81\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote:\u003c/strong\u003e SSI = surgical site infection. P-values are based on chi-square (\u0026chi;\u0026sup2;) tests for categorical variables and independent-samples t-tests for continuous variables. Bold values denote statistical significance at the p-value \u0026lt;0.05 level.\u003c/p\u003e\n\u003ch2\u003eSubgroup variations in the effect of previous history of CS on SSIs\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eA pre-planned subgroup analysis was conducted to evaluate whether the association between prior history of cesarean section (repeat CS cohort) and SSI was consistent across different patient populations and clinical settings. The results demonstrated that the magnitude of SSI risk varied by hospital type, type of CS, BMI, underlying medical conditions, and preoperative skin preparation method.\u003c/p\u003e\n\u003cp\u003eWomen delivering in referral and teaching hospitals experienced the highest increase in SSI risk associated with prior CS (RR: 4.30; 95% CI: 2.72\u0026ndash;6.80), whereas the risk was lower and not statistically significant in primary hospitals (RR: 1.67; 95% CI: 0.81\u0026ndash;3.45; p-interaction = 0.025). Emergent CS procedures were associated with a higher SSI risk compared to elective CS.\u003c/p\u003e\n\u003cp\u003eAmong women with BMI \u0026lt;30 kg/m\u0026sup2;, prior CS markedly increased SSI risk (RR: 4.20; 95% CI: 2.88\u0026ndash;6.12), while no significant risk increase was observed in women with BMI \u0026ge;30 kg/m\u0026sup2;. Similarly, the risk increase was more pronounced in women without underlying medical conditions (RR: 3.54; 95% CI: 2.32\u0026ndash;5.40; p-interaction \u0026lt;0.001).\u003c/p\u003e\n\u003cp\u003eRegarding preoperative skin preparation, aqueous povidone-iodine was associated with the highest SSI risk in the repeat CS cohort (RR: 4.93; 95% CI: 2.83\u0026ndash;8.60), whereas chlorhexidine-alcohol served as the reference with the lowest SSI rates. No significant effect modification was observed for prolonged rupture of membranes (PROM) status (p-interaction = 0.22), indicating that prior CS increased SSI risk regardless of PROM. Overall, our analysis indicate that repeat CS is a strong independent risk factor for SSI, and its impact is influenced by patient, procedural, and hospital-related factors.\u003c/p\u003e\n\u003ch2\u003eIntraoperative Complications and surgical outcomes by type of CS\u003c/h2\u003e\n\u003cp\u003eAmong the secondary outcomes, significant differences were observed between women who underwent repeat cesarean section (CS) and those with a first CS (Table 3). The use of general anesthesia was higher in the repeat CS group (20.6%) compared to the first CS group (15.9%), with a 30% increased risk (RR = 1.30, 95% CI: 1.05\u0026ndash;1.61, \u003cem\u003ep = 0.018\u003c/em\u003e). The mean operative time was markedly longer in women with repeat CS (59.0 \u0026plusmn; 11.0 minutes) than in those undergoing a first CS (40.1 \u0026plusmn; 9.0 minutes) (p \u0026lt; 0.001). Intra-operative maternal complications were also more frequent in the repeat CS group. Blood transfusion or significant bleeding occurred in 23.9% of repeat CS compared with 13.9% in first CS, corresponding to a 71% higher risk (RR = 1.71, 95% CI: 1.43\u0026ndash;2.06, \u003cem\u003ep \u0026lt; 0.001).\u003c/em\u003e Dense adhesions were detected in 4.8% of women with repeat CS compared with only 0.4% among first CS (RR = 12.0, 95% CI: 3.7\u0026ndash;38.4, \u003cem\u003ep \u0026lt; 0.001\u003c/em\u003e). Placenta previa was also more common in the repeat CS group (2.0% vs. 0.7%; RR = 3.0, 95% CI: 1.1\u0026ndash;8.1,\u003cem\u003e\u0026nbsp;p = 0.030).\u0026nbsp;\u003c/em\u003eRegarding post-operative outcomes, prophylactic use of systemic antibiotics was substantially higher in women with repeat CS (97.6%) than in those with first CS (58.9%) (RR = 1.65, 95% CI: 1.57\u0026ndash;1.75, \u003cem\u003ep \u0026lt; 0.001\u003c/em\u003e). The mean hospital stay was significantly prolonged among repeat CS patients (3.8 days vs. 1.3 days, \u003cem\u003ep \u0026lt; 0.001\u003c/em\u003e). Moreover, hospital readmissions were almost threefold higher in the repeat CS group compared to first CS (12.6% vs. 4.2%; RR = 2.97, 95% CI: 1.99\u0026ndash;4.45)\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 3\u003c/strong\u003e: Maternal complications, intraoperative events, and post-operative outcomes among women undergoing repeat CS (n=753) compared with first CS (n=753) at three hospitals in South Ethiopia\u003c/p\u003e\n\u003ctable border=\"0\" cellspacing=\"0\" cellpadding=\"0\" width=\"721\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSecondary outcomes\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eRepeat CS\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eFirst CS (control)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eRR(95%CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eNo (%)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntraoperative events\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003eGeneral anesthesia used\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e275 (18.26)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e155 (20.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e120 (15.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1.30(1.05-1.61)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.018\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003eOperation time(min) (Mean \u0026plusmn; SD)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e49.56 \u0026plusmn; 11.5\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e59 \u0026plusmn;11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e40.12\u0026plusmn;9\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"5\" valign=\"top\" style=\"width: 529px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eIntra-operative maternal complication\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003eBlood transfusion/bleeding\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e285 (18.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e180 (23.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e105 (13.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1.71(1.43-2.06)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003eDense adhesion\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e39(2.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e36(4.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e3(0.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e12.0(3.7\u0026ndash;38.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 193px;\"\u003e\n \u003cp\u003ePlacenta previa \u0026nbsp; \u0026nbsp;\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e20(1.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e15(2.0)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e5(0.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e3.0 (1.1\u0026ndash;8.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"8\" valign=\"top\" style=\"width: 721px;\"\u003e\n \u003cp\u003e\u003cstrong\u003ePost-operative complications in the hospital\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003ePost-operative SAP\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e1178(78.3)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e735 (97.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e444 (58.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e1.65(1.57-1.75)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u0026lt;\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003eLength of hospital stay\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e2.6 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e3.8 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e1.3 days\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e-\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 72px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd colspan=\"2\" valign=\"top\" style=\"width: 199px;\"\u003e\n \u003cp\u003eReadmission \u0026nbsp;for any reason\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 93px;\"\u003e\n \u003cp\u003e121 (8.03)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 99px;\"\u003e\n \u003cp\u003e95 (12.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e32 (4.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 120px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.97(1.99-4.45)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd style=\"width: 12px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003eNote\u003c/strong\u003e: Reaped CS group combined all women who had any previous CS, \u003cstrong\u003eRR\u003c/strong\u003e; Relative Risk, SAP; surgical antibiotic prophylaxis, \u003cstrong\u003eCS\u003c/strong\u003e; cesarean section\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBold values denote statistical significance at the p-value \u0026lt;0.05 level\u003c/p\u003e\n\u003ch2\u003eMicrobiology of SSI after CS by first time and repeat CS \u0026nbsp; \u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eOf the 181 culture-proven SSI, 106 (58%) were caused by pure Gram-negative bacilli, predominantly \u003cem\u003eKlebsiella pneumoniae\u003c/em\u003e (26.0%), \u003cem\u003ePseudomonas aeruginosa\u003c/em\u003e (14.4%), and \u003cem\u003eEscherichia coli\u003c/em\u003e (12.7%). Gram-positive bacteria accounted for 24.9% of SSIs, predominantly \u003cem\u003eStaphylococcus aureus\u003c/em\u003e (15.5%), followed by coagulase-negative staphylococci (CoNS) (6.1%) and \u003cem\u003eEnterococcus faecium\u003c/em\u003e (3.3%). A statistically significant difference was observed in the bacterial profile of SSI due to monobacteria between first and repeat CS groups; with Gram-negative isolates more frequent among repeat CS patients, whereas Gram-positive bacteria were relatively more common in first-time CS. Among polymicrobial infections, the most frequent combinations included \u003cem\u003eP. aeruginosa with S. aureus\u003c/em\u003e (6.1%), \u003cem\u003eE. coli\u003c/em\u003e with K\u003cem\u003e. pneumoniae\u003c/em\u003e (4.4%), and K. \u003cem\u003epneumoniae\u003c/em\u003e with \u003cem\u003eS. aureus\u003c/em\u003e (2.2%). These patterns suggest a diverse microbial etiology, with a predominance of Gram-negative bacteria in repeat CS-related SSIs and notable Gram-positive contributions in first-time CS infections. Detailed distribution of individual pathogens by cesarean section type is presented in \u003cstrong\u003eFigure 2\u003c/strong\u003e\u003c/p\u003e\n\u003ch2\u003eEffect of priory CS on the incidence of SSI\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eIn bivariate analyses using Poisson regression with robust variance, all variables with p \u0026lt; 0.25 were considered as candidates for the multivariable model. These included age, residence, prolonged labor, BMI, prior hospitalization, being in labor at CS, vaginal examinations, urgency of the procedure, general anesthesia, and preoperative skin preparation. In the multivariable model, repeat CS was the main exposure of interest, and the other variables were included as covariates to control for potential confounding. After adjustment, repeat CS remained strongly associated with an increased risk of SSI (adjusted RR = 2.94, 95% CI: 2.20\u0026ndash;3.93, \u003cem\u003ep \u0026lt; 0.001\u003c/em\u003e). Other factors that were independently associated with SSI included prior hospitalization (adjusted RR = 1.56, 95% CI: 1.18\u0026ndash;2.10, \u003cem\u003ep = 0.002\u003c/em\u003e), emergency CS (adjusted RR = 1.76, 95% CI: 1.06\u0026ndash;2.91, \u003cem\u003ep = 0.03\u003c/em\u003e), and preoperative skin preparation with aqueous povidone-iodine (10%) (adjusted RR = 2.12, 95% CI: 1.41\u0026ndash;3.19, \u003cem\u003ep = 0.001\u003c/em\u003e) (\u003cstrong\u003eTable 4).\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eTable 4\u003c/strong\u003e: Bivariable and multivariable analysis of risk factors associated with SSI after CS among women underwent at three hospitals in the south Ethiopia region\u003c/p\u003e\n\u003ctable border=\"1\" cellspacing=\"0\" cellpadding=\"0\" width=\"841\" class=\"fr-table-selection-hover\"\u003e\n \u003ctbody\u003e\n \u003ctr\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003eCharacteristics\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAll\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(n)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eSSI (Yes)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eCrude RR\u0026nbsp;\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003eAdjusted RR\u003c/strong\u003e\u003c/p\u003e\n \u003cp\u003e\u003cstrong\u003e(95% CI)*\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd rowspan=\"2\" valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u003cem\u003ep-value\u003c/em\u003e\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003eNo (%)\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eRepeat CS (\u0026ge; 1CS) (yes/no)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e(753)/(753)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e153(20.3)/51(6.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2.98 (2.21\u0026ndash;4.02)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026lt;0.001\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.94 (2.20\u0026ndash;3.93)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e\u0026lt;0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAge (\u0026gt;30 years (vs. \u0026lt; 20 years)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e429 (28.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e79/\u003cstrong\u003e\u0026nbsp;(18.4)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.32 (0.97\u0026ndash;1.80)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.08\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eResidence (Urban/Rural)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e710/796\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e84 (11.8)/ 20(15.1)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.28 (0.95\u0026ndash;1.72)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.11\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eBMI (per 1-unit increase)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e(1506)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e204(13.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.04 (0.99\u0026ndash;1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e1.04 (0.99\u0026ndash;1.09)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.05\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePrior hospitalization (Y/N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e(204)/(1302)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e62 30.3)/142(10.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2.79 (1.28\u0026ndash;2.97)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.002\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.56 (1.18\u0026ndash;2.10)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.002\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eProlonged labor \u0026gt;24h(Y/N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e115 (7.6)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e32(27.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e2.01 (0.97\u0026ndash;2.87)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.06\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eIn labor at CS (Y/N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1,150 (76.4)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e143(12.43)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.25 (0.89\u0026ndash;1.76)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.20\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eVaginal examination (Y/N)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e1,170 (77.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e181(15.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.30 (0.95\u0026ndash;1.78)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.10\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eEmergency CS(vs. Elective)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e(1158)/(416)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e173(14.9)/31(7.5)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.99(1.17\u0026ndash;2.41)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.004\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.76 (1.06\u0026ndash;2.91)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.03\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eGeneral anesthesia (Y/N)\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e(275)/(1231)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e59(21.5)/145(11.8)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.82 (0.98\u0026ndash;1.82)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.07\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e1.32 (0.98\u0026ndash;1.77)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.06\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003ePreoperative skin preparation\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eAqueous povidone iodine\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e(179)/(1327)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e35 19.5)/169(12.7)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.54 (0.92\u0026ndash;2.28)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.1\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e2.12 (1.41\u0026ndash;3.19)\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u003cstrong\u003e0.001\u003c/strong\u003e\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eIodine + alcohol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e756 (50.2)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e112/756\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003e1.13 (0.82\u0026ndash;1.56\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e0.45\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eNS\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003ctr\u003e\n \u003ctd valign=\"top\" style=\"width: 217px;\"\u003e\n \u003cp\u003eChlorhexidine + alcohol\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 108px;\"\u003e\n \u003cp\u003e571 (37.9)\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 138px;\"\u003e\n \u003cp\u003e43/572\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 132px;\"\u003e\n \u003cp\u003eReference group\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 126px;\"\u003e\n \u003cp\u003eReference\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003ctd valign=\"top\" style=\"width: 60px;\"\u003e\n \u003cp\u003e\u0026nbsp;\u003c/p\u003e\n \u003c/td\u003e\n \u003c/tr\u003e\n \u003c/tbody\u003e\n\u003c/table\u003e\n\u003cp\u003e\u003cstrong\u003e\u003cem\u003eAbbreviations\u003c/em\u003e\u003c/strong\u003e\u003cem\u003e:\u0026nbsp;\u003c/em\u003eBMI, Body Mass Index; RR, relative risk or risk ratio; CI, confidence interval; \u003cstrong\u003eNS\u003c/strong\u003e, Non-significant\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e*Adjusted for: case-mix,\u0026nbsp;(Y/N: Yes, or No,\u003c/p\u003e\n\u003cp\u003eBold values are the significant differences, with a confidence interval that does not cross 1\u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis prospective cohort study found a baseline incidence of surgical site infection (SSI) following cesarean section (CS) of 13.5 %( 95%CI: 11.9-15.4)\u0026nbsp;among women in public hospitals in southern Ethiopia. This highlights a substantial burden of postoperative infection and is consistent with estimates from other low and middle-income countries (LMICs) and regional data from Sub-Saharan Africa\u0026nbsp;[13, 22]. While comparable to pooled national estimates for Ethiopia (9.7% to 25.4%)\u0026nbsp;[9]\u0026nbsp;and individual study from Harer Ethiopia\u0026nbsp;[23], lower than the 25.4% reported from Debretabor north Ethiopia\u0026nbsp;[13]. The observed incidence varied regionally, likely reflecting differences in infection-prevention protocols, perioperative antibiotic use, and local antimicrobial resistance patterns. Importantly, this rate remains considerably higher than the \u0026lt;5% typically reported in high-income settings\u0026nbsp;[24, 25]\u0026nbsp;underscoring the need for targeted interventions.\u003c/p\u003e\n\u003cp\u003eThe most salient finding was that a history of prior CS was the strongest independent predictor of SSI, nearly tripling the risk compared with primary CS (aRR = 2.94, 95% CI: 2.20\u0026ndash;3.93, \u003cem\u003ep \u0026lt; 0.001).\u003c/em\u003e This is consistent with prior evidence demonstrating repeat CS as a major driver of postoperative infection\u0026nbsp;[26\u0026ndash;28]. The increased risk is mechanistically linked to adhesions and scar tissue from prior surgeries, which prolong operative time, increase tissue trauma, and impair vascular perfusion, creating a favorable environment for bacterial colonization\u0026nbsp;[29, 30]. These findings underscore the need to treat repeat CS as a high-risk surgical event requiring enhanced perioperative planning and vigilant postoperative monitoring.\u003c/p\u003e\n\u003cp\u003eOur analyses revealed that the effect of prior CS on SSI risk was not uniform but varied across clinical and institutional contexts. The risk was notably higher in emergency versus elective procedures, consistent with prior studies linking emergency operations to prolonged labor exposure and increased intraoperative contamination\u0026nbsp;[27, 31]. Additionally, the effect was more pronounced in referral and teaching hospitals compared with primary-level facilities, likely due to referral bias, as higher-acuity institutions manage more complex cases with inherently greater surgical risk\u0026nbsp;[30, 32]. Preoperative skin antisepsis was a key modifiable factor influencing SSI risk. Chlorhexidine-alcohol was associated with the lowest risk, whereas\u0026nbsp;aqueous povidone-iodine (10%) associated with higher risk\u0026nbsp;(aRR = 2.12, 95% CI: 1.41\u0026ndash;3.19), aligning with evidence from randomized trials showing superior efficacy of chlorhexidine-alcohol in abdominal surgery\u0026nbsp;[28, 33]. A dose-response relationship was also observed: SSI risk increased with the number of prior CS, consistent with earlier findings\u0026nbsp;[30].\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eBeyond SSI, prior CS significantly increased intraoperative and postoperative morbidity. Women with previous CS experienced longer operative times, higher transfusion rates, more adhesions, and greater prevalence of placenta previa, reflecting the cumulative risks of multiple surgeries\u0026nbsp;[16, 30]. However, other previous studies did not find the elevated requirement for blood transfusion. for example Uyanikoglu etal.(2016)\u0026nbsp;[14]\u0026nbsp; \u0026nbsp;did not find differences in the incidence of peripartum hemorrhage and blood Transfusion in women with four or more CS compared to those with three or more. Postoperatively, these women had prolonged hospital stays and higher rates of extended antibiotic use, indicating increased resource utilization and heightened exposure to nosocomial pathogens, including multidrug-resistant organisms\u0026nbsp;[34, 35].The microbiological spectrum differed between primary and repeat CS. SSIs following repeat CS were predominantly caused by Gram-negative bacilli, especially \u003cem\u003eK. pneumoniae,\u003c/em\u003e whereas SSIs after primary CS were mainly due to Gram-positive organisms, primarily \u003cem\u003eS. aureus.\u003c/em\u003e This shift toward Gram-negative pathogens has been reported in other LMICs and likely reflects prior healthcare exposure, antibiotic use, and contamination facilitated by intra-abdominal adhesions\u0026nbsp;[36, 37]. These findings have critical implications for empirical antibiotic therapy in high-risk women. SSI after CS is multifactorial. Significant independent predictors included use of\u0026nbsp;aqueous povidone-iodine (10%), priory\u0026nbsp;hospitalization (aRR = 1.56), emergency CS (aRR = 1.76), and higher BMI (borderline significance). The link with recent hospitalization highlights the risk of colonization with multidrug-resistant organisms, emphasizing the need for robust infection control and context-specific antibiotic stewardship. Overall a history of prior CS significantly increases the risk of SSI and broader maternal morbidity, with effects magnified in emergency settings and modifiable through optimized skin antisepsis. The shift toward Gram-negative pathogens in repeat CS underscores the need to reconsider empirical antibiotic strategies for high-risk groups.\u003c/p\u003e\n\u003ch2\u003eImplications\u0026nbsp;\u003c/h2\u003e\n\u003cp\u003eThese new data are an important addition to the growing number of reports showing that repeat CS could be more complex procedure than first CS across all setting and impacting maternal health and increase surgical complexity. The findings from our study have several important implications for clinical practice and health policy in Ethiopia. First, there is a need for targeted infection prevention strategies for women undergoing repeat cesarean sections. These strategies should include the use of evidence-based preoperative antiseptic agents, such as iodine-alcohol or chlorhexidine-alcohol, to reduce the risk of infection\u0026nbsp;[24, 38].\u0026nbsp;Second, given the increased risk of SSI associated with emergency procedures, efforts should be made to improve the timing and quality of cesarean sections. This includes enhancing the availability of surgical services, improving the skills of healthcare providers, and ensuring the availability of necessary surgical supplies and equipment\u0026nbsp;[18].\u0026nbsp;Third, the observed differences in infection rates across different hospital tiers suggest that there may be disparities in the quality of care provided. Strengthening infection prevention and control measures, standardizing surgical protocols, and improving the infrastructure of lower-level facilities could help reduce the incidence of SSI and improve maternal outcomes\u0026nbsp;[39]. Finally, the shift in the microbiological profile of SSIs underscores the need for ongoing surveillance of bacterial pathogens and antimicrobial resistance patterns. This information is crucial for developing and updating local antibiotic guidelines and for implementing effective antimicrobial stewardship programs\u0026nbsp;[40].\u003c/p\u003e\n\u003ch2\u003eStrengths and Limitations\u003c/h2\u003e\n\u003cp\u003eTo the best of our knowledge, this is the first prospective cohort study with a large sample size to assess the effect of prior CS on incidence of SSIs, microbial pathogens, and other interpretative and process outcomes. The strength of the study was the prospective multicenter study design, integration of both epidemiological and microbiological data enhances understanding of pathogen-specific risks, particularly the predominance of Gram-negative organisms in repeat CS. It supports evidence-based perioperative management and antibiotic stewardship. This study also analyzed primary prospective data that used pretested, standardized data collection forms collected by well-trained research assistants to strengthen the quality of data.\u0026nbsp;While the observational design of the study may introduce biases, the robust multivariable regression analysis strengthens the validity of the findings. The study\u0026apos;s ability to control for key potential confounders enhances the reliability of the identified risk factors. Based on the large sample size analysis, the key results of the study will be generalized to the whole population of women undergoing CS in similar settings across resource-limited countries.\u003c/p\u003e\n\u003cp\u003eNevertheless, the study has \u003cstrong\u003elimitations\u003c/strong\u003e. First, it was conducted in a limited geographic region and three hospitals, which may affect generalizability to other settings. Second, microbiological cultures were not obtained for all SSI cases, potentially underestimating pathogen diversity and the prevalence of multidrug-resistant organisms. Third, elective CSs were underrepresented, limiting the assessment of SSI risk in this group, and women with specific comorbidities (e.g., diabetes, heart disease, or premature rupture of membranes) were excluded because of mandated postoperative antibiotics, which may have influenced the observed SSI rates. The other notable limitation of this study is the incomplete information (missed anaerobic pathogens and antimicrobial susceptibility), the effect of repeat CS on neonatal outcomes, which complicates the assessment of overall impact. Finally, all preventive measures and exposures were assessed simultaneously, limiting the ability to determine the relative contribution of each factor to SSI risk.\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThe study findings demonstrate that the likelihood and severity of surgical site infections (SSIs), particularly deep incisional predominantly caused by Gram-negative pathogens and increase with a prior history of cesarean section in a dose\u0026ndash;response relationship. These risks are further amplified in emergency procedures, high-acuity hospitals, urgent surgeries, and cases with inadequate preoperative skin preparation. Women undergoing repeat CS are also at heightened risk of intraoperative complications and technical challenges, including prolonged operative time, dense adhesions, greater need for general anesthesia, and increased blood transfusion requirements. Repeat CS is additionally linked with prolonged hospital stays and extended courses of antibiotic prophylaxis.\u003c/p\u003e\n\u003cp\u003eThese findings highlight the critical need for robust preoperative counseling, individualized risk stratification, meticulous surgical planning, and enhanced diagnostic, surveillance, and postoperative monitoring, particularly in low-resource settings where managing complications is more difficult. Healthcare providers should be proactive in informing women of the risks associated with prior CS and prioritize limiting primary cesarean deliveries to cases with clear medical indications. This baseline data provides a foundation for future research to identify and implement effective interventions targeting high-risk subgroups, with the ultimate goal of improving maternal outcomes, surgical safety, and quality of care in LMIC settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eEthical Considerations\u003c/h2\u003e\n\u003cp\u003eEthical approval was obtained from the Institutional Review Board of Arba Minch University, College of Medicine and Health Sciences, Department of Medical Laboratory Science (IRB No. 1045/21/22). Permission letters were secured from the respective hospital managements. The study\u0026apos;s objectives, benefits, and potential risks were clearly communicated to participants, who were informed that participation was voluntary and could be withdrawn at any time without penalty. Written informed consent was obtained from participants before the commencement of data collection. All data were de-identified and coded with a unique identifier that is linked to their identity key before starting analysis. All electronic data was kept on a password-protected computer, while all paper documents were stored in a locked file cabinet at the study centre. Only the principal investigator had access to the identity key. Microbiological analyses related to this research were provided free of charge, and positive findings were promptly communicated to treating physicians and patients for appropriate management. The study adhered to the principles outlined in the Declaration of Helsinki and complied with national and institutional ethical guidelines for research involving human subjects.\u003c/p\u003e\n\u003ch2\u003eConsent for publication\u003c/h2\u003e\n\u003cp\u003eNot applicable. This manuscript does not contain any person\u0026apos;s data in any form (including images, videos, or clinical details).\u003c/p\u003e\n\u003ch2\u003eAvailability of data and materials\u003c/h2\u003e\n\u003cp\u003eThe datasets used and/or analyzed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch2\u003eCompeting interests\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003eFunding statement\u003c/h2\u003e\n\u003cp\u003eThis research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003ch2\u003eAuthor contribution statement\u003c/h2\u003e\n\u003cp\u003eConceptualized and designed the study: SM, KT, MA, and TM\u003c/p\u003e\n\u003cp\u003eCollected the data and supervision: TD, AA, and KT\u003c/p\u003e\n\u003cp\u003ePerformed and monitoring microbiology work; KT, KK, TD, and TM\u003c/p\u003e\n\u003cp\u003eVisualization: TD, AA, KT\u003c/p\u003e\n\u003cp\u003eProject management, funding acquisition, and supervision; TM, SM, and MA\u003c/p\u003e\n\u003cp\u003eFormal analysis, software, and interpreted the data: KT, MA, SM, and AA\u003c/p\u003e\n\u003cp\u003eDraft the Original manuscript and revise the writing: SM, KT, MA, TD\u003c/p\u003e\n\u003cp\u003eWriting the final manuscript, editing, and Validation: SM, KT, AA, KK, and TD\u003c/p\u003e\n\u003cp\u003eAll authors reviewed and approved the final manuscript\u003c/p\u003e\n\u003ch2\u003eDeclaration of Interests Statement\u003c/h2\u003e\n\u003cp\u003eThe authors declare no conflict of interest.\u003c/p\u003e\n\u003ch2\u003eAcknowledgments\u003c/h2\u003e\n\u003cp\u003eThe authors thank the many healthcare professionals at each participating hospital who assisted with the conduct of the surveillance, including the surveillance nurses, clinical microbiology laboratory personnel, and the physicians and nurses providing care for the patients during the study. This work would not have been possible without their cooperation and generous assistance\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eMylonas I. Cesarean section: epidemiology, trends, and outcomes. American Journal of Obstetrics and Gynecology. 2011;205:11\u0026ndash;20. https://doi.org/10.1016/j.ajog.2011.02.038.\u003c/li\u003e\n\u003cli\u003eVillar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, et al.,. WHO systematic review of cesarean section rates. American Journal of Obstetrics and Gynecology. 2013;208:214.e1-214.e11. https://doi.org/10.1016/j.ajog.2012.12.006.\u003c/li\u003e\n\u003cli\u003eSilver RM. Maternal morbidity associated with multiple repeat cesarean deliveries. Obstetrics \u0026amp; Gynecology. 2010;115:792\u0026ndash;800. https://doi.org/10.1097/AOG.0b013e3181d04004.\u003c/li\u003e\n\u003cli\u003eTita ATN, Landon MB. Cesarean delivery: maternal complications. New England Journal of Medicine. 2016;374:1040\u0026ndash;50. https://doi.org/10.1056/NEJMra1515243.\u003c/li\u003e\n\u003cli\u003eOlsen MA, Butler AM, Willers DM, Devkota P, Fraser VJ, Dubberke ER, et al. Risk factors for surgical site infection after cesarean delivery: a systematic review. American Journal of Infection Control. 2018;46:1272\u0026ndash;80. https://doi.org/10.1016/j.ajic.2018.02.015.\u003c/li\u003e\n\u003cli\u003eKaplanoglu M, Bulbul M, Kaplanoglu D, Bakacak SM. Effect of Multiple Repeat Cesarean Sections on Maternal Morbidity: Data from Southeast Turkey. Med Sci Monit. 2015;21:1447\u0026ndash;53. https://doi.org/10.12659/MSM.893333.\u003c/li\u003e\n\u003cli\u003eGalyean AM, Lagrew DC, Bush MC, Kurtzman JT. Previous cesarean section and the risk of postpartum maternal complications and adverse neonatal outcomes in future pregnancies. J Perinatol. 2009;29:726\u0026ndash;30. https://doi.org/10.1038/jp.2009.108.\u003c/li\u003e\n\u003cli\u003eZuarez-Easton S, Zafran N, Garmi G, Salim R. Postcesarean wound infection: prevalence, impact, prevention, and management challenges. Int J Womens Health. 2017;9:81\u0026ndash;8. https://doi.org/10.2147/IJWH.S98876.\u003c/li\u003e\n\u003cli\u003eMezemir R, Olayemi O, Dessie Y. Incidence and predictors of surgical site infection after cesarean section in Ethiopia. International Journal of Women\u0026rsquo;s Health. 2023;15:1547\u0026ndash;60. https://doi.org/10.2147/IJWH.S354789.\u003c/li\u003e\n\u003cli\u003eKwee A, de Boer M, van der Veen F, al et. Surgical complexity and maternal outcomes in repeat cesarean section. Obstetrics \u0026amp; Gynecology. 2020;136:1235\u0026ndash;43. https://doi.org/10.1097/AOG.0000000000004023.\u003c/li\u003e\n\u003cli\u003eSurgical Site Infection (SSI) | HAI | CDC. 2021. https://www.cdc.gov/hai/ssi/ssi.html. Accessed 12 June 2022.\u003c/li\u003e\n\u003cli\u003eKasiulevičius V, \u0026Scaron;apoka V, Filipavičiūtė R. Sample Size Calculation in Epidemiological Studies. Gerontologija. 2006;7:225\u0026ndash;31.\u003c/li\u003e\n\u003cli\u003eBitew A, Yismaw G, Gizeyatu A, Wolde B. Prevalence of Surgical Site Infection and Associated Factors among Women Underwent Cesarean Delivery in Debretabor Town Health Institutions, Northwest Ethiopia: A Cross-Sectional Study. BMC Pregnancy and Childbirth. 2023;23:108. https://doi.org/10.1186/s12884-023-05424-9.\u003c/li\u003e\n\u003cli\u003eUyanikoglu H, Karahan MA, Turp AB, others. The Effect of the Number of Previous Cesarean Deliveries on Maternal and Perinatal Outcomes. Ginekologia Polska. 2016;87:431\u0026ndash;5. https://doi.org/10.5603/GP.2016.0024.\u003c/li\u003e\n\u003cli\u003eAlemu M, Ayana D, Tadese M, Taye B. Determinants of Surgical Site Infection after Cesarean Section in Ethiopia: A Systematic Review and Meta-Analysis. BMC Women\u0026rsquo;s Health. 2023;23:237. https://doi.org/10.1186/s12905-023-02383-3.\u003c/li\u003e\n\u003cli\u003eMarshall NE, Fu R, Guise JM. Impact of Multiple Cesarean Deliveries on Maternal Morbidity: A Systematic Review. American Journal of Obstetrics and Gynecology. 2011;205:262.e1-8. https://doi.org/10.1016/j.ajog.2011.06.035.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. Protocol for surgical site infection surveillance with a focus on settings with limited resources. Geneva: World Health Organization; 2018 Mar 31. Available from: https://www.who.int/publications/i/item/protocol-for-surgical-site-infection-surveillance-with-a-focus-on-settings-with-limited-resources\u003c/li\u003e\n\u003cli\u003eOp\u0026oslash;ien HK, Valb\u0026oslash; A, Grinde-Andersen A, Walberg M. Post-Cesarean Surgical Site Infections according to CDC Standards: Rates and Risk Factors. A Prospective Cohort Study. Acta Obstetricia et Gynecologica Scandinavica. 2007;86:1097\u0026ndash;102. https://doi.org/10.1080/00016340701515225.\u003c/li\u003e\n\u003cli\u003eBasic laboratory procedures in clinical bacteriology, 2nd ed. https://www.who.int/publications/i/item/9241545453. Accessed 27 Aug 2024.\u003c/li\u003e\n\u003cli\u003eRuan J. [Bergey\u0026rsquo;s Manual of Systematic Bacteriology (second edition) Volume 5 and the study of Actinomycetes systematic in China]. Wei Sheng Wu Xue Bao. 2013;53:521\u0026ndash;30.\u003c/li\u003e\n\u003cli\u003eWeinstein, M. P. \u0026amp; L JS. Clinical Laboratory Standards Institute (CLSI).Performance Standards for Antimicrobial Susceptibility Testing,. In: Clinical \u0026amp; Laboratory Standards Institute. 32nd Edition. USA: 940 Wayne, PA, U.S.A.; 2022. p. 362.\u003c/li\u003e\n\u003cli\u003eTsegaye S, Tsegaye Y, Tadese M, Kassa M. Surgical Site Infection and Associated Factors among Women Undergoing Cesarean Section in Ethiopia: A Systematic Review and Meta-Analysis. BMC Pregnancy and Childbirth. 2022;22:825. https://doi.org/10.1186/s12884-022-05160-6.\u003c/li\u003e\n\u003cli\u003eAlemye T, Oljira L, Fekadu G, Mengesha MM. Post cesarean section surgical site infection and associated factors among women who delivered in public hospitals in Harar city, Eastern Ethiopia: A hospital-based analytic cross-sectional study. PLOS ONE. 2021;16:e0253194. https://doi.org/10.1371/journal.pone.0253194.\u003c/li\u003e\n\u003cli\u003eBetr\u0026aacute;n AP, Torloni MR, Zhang J, G\u0026uuml;lmezoglu AM, WHO Working Group on Caesarean Section. WHO Statement on Caesarean Section Rates. BJOG: An International Journal of Obstetrics \u0026amp; Gynaecology. 2016;123:667\u0026ndash;70. https://doi.org/10.1111/1471-0528.13526.\u003c/li\u003e\n\u003cli\u003eOwens CD, Stoessel K. Surgical Site Infections: Epidemiology, Microbiology and Prevention. The Journal of Hospital Infection. 2008;70 Suppl 2:3\u0026ndash;10. https://doi.org/10.1016/S0195-6701(08)60017-1.\u003c/li\u003e\n\u003cli\u003eCheng Y, Cao L, Zhang Z, others. Risk Factors for Surgical Site Infection after Cesarean Delivery: A Systematic Review and Meta-Analysis. American Journal of Infection Control. 2023;51:443\u0026ndash;51. https://doi.org/10.1016/j.ajic.2022.08.028.\u003c/li\u003e\n\u003cli\u003eWloch C, Wilson J, Lamagni T, Harrington P, Charlett A, Sheridan E. Risk Factors for Surgical Site Infection Following Caesarean Section in England: Results from a Multicentre Cohort Study. BJOG: An International Journal of Obstetrics \u0026amp; Gynaecology. 2012;119:1324\u0026ndash;33. https://doi.org/10.1111/j.1471-0528.2012.03452.x.\u003c/li\u003e\n\u003cli\u003eTuuli MG, Liu J, Stout MJ, others. A Randomized Trial Comparing Skin Antiseptic Agents at Cesarean Delivery. New England Journal of Medicine. 2016;374:647\u0026ndash;55. https://doi.org/10.1056/NEJMoa1511048.\u003c/li\u003e\n\u003cli\u003eGyamfi-Bannerman C, Srinivas SP, Wright JD, others. Postpartum Hemorrhage Outcomes and Race. American Journal of Obstetrics and Gynecology. 2023;229:675.e1-675.e18. https://doi.org/10.1016/j.ajog.2023.05.009.\u003c/li\u003e\n\u003cli\u003eSilver RM. Delivery after Previous Cesarean: Long-Term Maternal Outcomes. Seminars in Perinatology. 2010;34:258\u0026ndash;66. https://doi.org/10.1053/j.semperi.2010.03.005.\u003c/li\u003e\n\u003cli\u003eNgonzi J, Bebell LM, Fajardo Y, others. Incidence of Postpartum Infection, Outcomes and Associated Risk Factors at Mbarara Regional Referral Hospital in Uganda. BMC Pregnancy and Childbirth. 2016;16:366. https://doi.org/10.1186/s12884-016-1135-1.\u003c/li\u003e\n\u003cli\u003eGurol-Urganci I, Bou-Antoun S, Lim CP, others. Impact of Caesarean Section on Subsequent Fertility: A Systematic Review and Meta-Analysis. Human Reproduction. 2013;28:1943\u0026ndash;52. https://doi.org/10.1093/humrep/det130.\u003c/li\u003e\n\u003cli\u003eNoorani A, Rabey N, Walsh SR, Davies RJ. Systematic Review and Meta-Analysis of Preoperative Antisepsis with Chlorhexidine versus Povidone-Iodine in Clean-Contaminated Surgery. British Journal of Surgery. 2010;97:1614\u0026ndash;20. https://doi.org/10.1002/bjs.7214.\u003c/li\u003e\n\u003cli\u003eGelaw B, Gebre-Selassie S, Tiruneh M, Mathios E, Yifru S. Isolation of Bacterial Pathogens from Patients with Postoperative Surgical Site Infections and Possible Sources of Infections at the University of Gondar Hospital, Northwest Ethiopia. Journal of Environmental and Public Health. 2023;2023:2123034. https://doi.org/10.1155/2023/2123034.\u003c/li\u003e\n\u003cli\u003eKaplanoglu M, Bulbul M, Kaplanoglu D, Bakacak SM, Tabak MS. Effect of Multiple Repeat Cesarean Sections on Maternal Morbidity and Mortality. The Journal of Maternal-Fetal \u0026amp; Neonatal Medicine. 2015;28:1059\u0026ndash;63. https://doi.org/10.3109/14767058.2014.942629.\u003c/li\u003e\n\u003cli\u003eAworh MK, Oduyebo O, Nwadiaro N, others. Microbiology of Surgical Site Infections in a Tertiary Hospital in Nigeria. Journal of Global Antimicrobial Resistance. 2020;22:176\u0026ndash;81. https://doi.org/10.1016/j.jgar.2020.02.023.\u003c/li\u003e\n\u003cli\u003eGebremariam T, Woldeamanuel GG, Asrat D, others. Microbial Etiology of Surgical Site Infections and Associated Antimicrobial Resistance Patterns in a Tertiary Hospital in Ethiopia. Infection and Drug Resistance. 2019;12:519\u0026ndash;27. https://doi.org/10.2147/IDR.S198373.\u003c/li\u003e\n\u003cli\u003eDarouiche RO, Wall MJJ, Itani KMF, others. Chlorhexidine-Alcohol versus Povidone-Iodine for Surgical-Site Antisepsis. New England Journal of Medicine. 2010;362:18\u0026ndash;26. https://doi.org/10.1056/NEJMoa0810988.\u003c/li\u003e\n\u003cli\u003eBetr\u0026aacute;n AP, Torloni MR, Zhang J, others. What Is the Optimal Rate of Caesarean Section at Population Level? A Systematic Review of Ecologic Studies. Reproductive Health. 2015;12:57. https://doi.org/10.1186/s12978-015-0043-6.\u003c/li\u003e\n\u003cli\u003eWorld Health Organization. WHO Recommendations for Prevention and Treatment of Maternal Peripartum Infections. Geneva: World Health Organization; 2016.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Cesarean section, repeat CS, surgical site infection, maternal morbidity, Ethiopia, peripartum infections","lastPublishedDoi":"10.21203/rs.3.rs-7502284/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7502284/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e\u003cp\u003eCesarean section (CS) is a widely performed lifesaving surgical procedure; however, it may also carry risks of maternal complications, especially with repeated exposure. Evidence from prospective studies in low-resource settings is limited. This study provides insights to guide interventions and implement maternal health policies for women undergoing repeat CS in low-resource settings like Ethiopia\u003c/p\u003e\u003ch2\u003eObjective\u003c/h2\u003e\u003cp\u003eTo assess whether prior CS increases the risk of postoperative surgical site infections (SSI), alters microbiological profiles, and contributes to intra- and postoperative complications compared with first-time CS.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA multicenter prospective cohort study was conducted from January to December 2022 among 1,506 women undergoing CS at one primary, one general, and one university comprehensive specialized hospital. Participants were enrolled into two cohorts: 753 women with \u0026ge;\u0026thinsp;1 prior CS (exposed) and 753 undergoing first-time CS (unexposed). All participants were followed for 30 days postoperatively. The primary outcome was SSI; secondary outcomes included SSI type, microbiology, and perioperative complications. Data were analyzed using SPSS v25 with Poisson regression and robust variance estimators; p-value\u0026thinsp;\u003cspan type=\"Underline\" class=\"Underline\" name=\"Emphasis\"\u003e\u0026le;\u003c/span\u003e\u0026thinsp;0.05 was considered statistically significant.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eOverall SSI incidence was 13.5% (95% CI: 11.9\u0026ndash;15.4%). Repeat CS had higher SSI rates than primary CS (20.3% vs. 6.8%; RR\u0026thinsp;=\u0026thinsp;2.98, 95% CI: 2.20\u0026ndash;4.03; \u003cem\u003ep\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/em\u003e), particularly deep incisional SSIs (30.1% vs. 9.8%; RR\u0026thinsp;=\u0026thinsp;3.07; \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.012\u003c/em\u003e). Gram-negative isolates predominated in repeat CS (83.8% vs. 68.6%; \u003cem\u003ep\u0026thinsp;=\u0026thinsp;0.027\u003c/em\u003e). Adjusted analyses confirmed repeat CS as a strong independent predictor of SSI (aRR\u0026thinsp;=\u0026thinsp;2.94, 95% CI: 2.20\u0026ndash;3.93). Risk was highest in the university comprehensive specialized hospital and emergency CS. Women with \u0026ge;\u0026thinsp;3 prior CS had nearly fourfold higher SSI risk. Repeat CS was also associated with longer operative time, greater use of general anesthesia, higher transfusion and antibiotic use, and longer hospital stay \u003cem\u003e(p\u0026thinsp;\u0026lt;\u0026thinsp;0.05).\u003c/em\u003e Additional independent predictors of SSI included emergency CS, history of hospitalization and aqueous povidone-iodine (10%) skin preparation with (aRR\u0026thinsp;=\u0026thinsp;1.76, 95% CI: 1.06\u0026ndash;2.91), (aRR\u0026thinsp;=\u0026thinsp;1.56, 95% CI: 1.18\u0026ndash;2.10), and (aRR\u0026thinsp;=\u0026thinsp;2.39, 95% CI: 1.45\u0026ndash;3.94), respectively.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eRepeat CS is associated with a threefold higher risk of SSI, more severe complications, and Gram-negative predominance. Risk-stratified interventions, optimized infection prevention, careful surgical planning, and antimicrobial stewardship are essential to improve outcomes\u003c/p\u003e","manuscriptTitle":"Impact of Prior Cesarean Section on Surgical Site Infections, Microbiological patterns, and Surgical Outcomes: A Prospective Multicenter Cohort Study in South Ethiopia","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-09-22 10:05:38","doi":"10.21203/rs.3.rs-7502284/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-11-05T09:36:42+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-05T00:10:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"222582433949509546316660590710484807328","date":"2025-11-04T22:36:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"79973964431901512616119034527228120019","date":"2025-11-04T21:22:26+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"303768028540175396740042824023393460515","date":"2025-11-04T21:17:19+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"175862545186536707507055094544835963098","date":"2025-11-04T21:06:00+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-28T04:55:58+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-09-23T07:00:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337303758104681644410864476782737068371","date":"2025-09-17T14:56:57+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247210262980948903173749651353840671834","date":"2025-09-16T22:39:22+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"187953162278382678068425274972399546152","date":"2025-09-13T00:55:30+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"320720664817739409450676393077929508946","date":"2025-09-12T08:17:12+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"280262256828545371264353476733176579907","date":"2025-09-12T00:48:57+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-11T22:32:17+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-09-02T04:09:35+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-01T08:55:44+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-01T08:52:29+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pregnancy and Childbirth","date":"2025-08-31T18:06:16+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pregnancy-and-childbirth","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"prch","sideBox":"Learn more about [BMC Pregnancy and Childbirth](http://bmcpregnancychildbirth.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/prch/default.aspx","title":"BMC Pregnancy and Childbirth","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"16398fef-1871-45b9-9448-616ad1d76a25","owner":[],"postedDate":"September 22nd, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-02-16T16:03:08+00:00","versionOfRecord":{"articleIdentity":"rs-7502284","link":"https://doi.org/10.1186/s12884-026-08795-x","journal":{"identity":"bmc-pregnancy-and-childbirth","isVorOnly":false,"title":"BMC Pregnancy and Childbirth"},"publishedOn":"2026-02-11 15:57:29","publishedOnDateReadable":"February 11th, 2026"},"versionCreatedAt":"2025-09-22 10:05:38","video":"","vorDoi":"10.1186/s12884-026-08795-x","vorDoiUrl":"https://doi.org/10.1186/s12884-026-08795-x","workflowStages":[]},"version":"v1","identity":"rs-7502284","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7502284","identity":"rs-7502284","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}