A prospective study of maternal, fetal and neonatal outcomes in the setting of cesarean section in low‐ and middle‐income countries

Abstract

Introduction Cesarean section (CS) rates are increasing globally with an unclear effect on pregnancy outcomes. The study objective was to quantify maternal and perinatal morbidity and mortality in low- and middle-income countries associated with CS compared to vaginal delivery (VD) both within and across sites. Material and methods A prospective population-based study including home and facility births in 337,153 women with a VD and 47,308 women with a CS from 2010 to 2015 was performed in Guatemala, India, Kenya, Pakistan, Zambia, and Democratic Republic of Congo. Women were enrolled during pregnancy; delivery and 6-week follow-up data were collected. Results Across all sites, CS rates increased from 8.6 to 15.2%, but remained low in African sites. Younger, nulliparous women were more likely to have a CS, as were women with higher education and those delivering a 1500–2499g infant. Across all sites, maternal and neonatal mortality was higher, and stillbirths lower, in pregnancies delivered by CS. Antepartum and postpartum complications as well as obstetric interventions and treatments were more common among women who underwent CS. In stratified analyses, all outcomes were worse in women with a CS compared to VD in African compared to non-African sites. Conclusions CS rates increased across all sites during the study period, but at more pronounced rates in the non-African sites. CS was associated with reducedpostpartum hemorrhage and lower rates of stillbirths in the non-African sites. In the African sites, CS was associated with an increase in all adverse outcomes. Further studies are necessary to better understand the increase in adverse outcomes with CS in the African sites.

Socioeconomic inequalities and determinants of maternal health services in Shaanxi Province, Western China

“…This suggested that the coverage of maternal health services utilization has been improved after years of development, which is consistent with the result of a study comparing the inequality status of maternal health services utilization before and after health care reform in Shaanxi Province[11]. The rates of C-section in our study exceeded the WHO recommended level and were also higher than those from other studies in Bangladesh and African sites [22, 23]. The high prevalence of C-section showed that some surgeries were likely to be clinically unnecessary.…”

Prospective cohort study comparing outcomes between vacuum extraction and second‐stage cesarean delivery at a Ugandan tertiary referral hospital

“…The present findings from Uganda were consistent with those from high‐income countries, indicating that vacuum extraction is a safe intervention and that SSCD carries an increased risk of maternal adverse events . Indeed, one study found maternal and neonatal mortality to be higher following cesarean delivery compared with vaginal, especially in African countries …”

“…A potential limitation of the present study was the observational design; however, a randomized trial would have been unethical owing to the exposure of many more participants to the increased risks of surgery and a lengthened waiting time, with increased risk of birth asphyxia and adverse maternal outcomes . Consequently, the current results must be interpreted with caution.…”

Framework for safe delivery: A call to action

“…In some African countries, cesarean deliveries are associated with a very high maternal and neonatal mortality and morbidity. This is due to the absence of facilities for instrumental vaginal delivery, delayed performance of CSs, and inadequate facilities/skills . In these countries the situation is even more complicated, since rural areas exhibit insufficiently low CS rates while urban areas exhibit exceedingly high CS rates.…”

“…This is due to the absence of facilities for instrumental vaginal delivery, delayed performance of CSs, and inadequate facilities/skills. 9 In these countries the situation is even more complicated, since rural areas exhibit insufficiently low CS rates while urban areas exhibit exceedingly high CS rates. The worldwide increase in cesarean deliveries needs to be "Too many CSs, too many episiotomies."…”