Method of Anesthesia and Perioperative Risk Factors, Maternal Anesthesia Complications, and Neonatal Mortality Following Cesarean Delivery in Africa: A Substudy of a 7-Day Prospective Observational Cohort Study
Authors: Gerber Carmen , Bishop David G. , Dyer Robert A. , Maswime Salome , Rodseth Reitze N. , van Dyk Dominique , Kluyts Hyla-Louise , Mbwele Bernard , Tumukunde Janat T. , Madzimbamuto Farai D. , Elkhogia Abdulaziz M. , Ndonga Andrew K. , Ngumi Zipporah W. W. , Omigbodun Akinyinka O. , Amanor-Boadu Simbo D. , Zoumenou Eugène , Basenero Apollo , Munlemvo Dolly M. , Coulibaly Youssouf , Ndayisaba Gabriel , Antwi-Kusi Akwasi , Gobin Veekash , Forget Patrice , Rakotoarison Sylvia , Samateh Ahmadou L. , Mehyaoui Ryad , Patel-Mujajati Ushmaben , Sani Chaibou M. , Madiba Thandinkozi E. , Pearse Rupert M. , Biccard Bruce M. ,   on behalf of the African Surgical Outcomes Study (ASOS) Investigators
Published: January 2024

BACKGROUND:
The African Surgical Outcomes Study (ASOS) found that maternal mortality following cesarean delivery in Africa is 50 times higher than in high-income countries, and associated with obstetric hemorrhage and anesthesia complications. Mothers who died were more likely to receive general anesthesia (GA). The associations between GA versus spinal anesthesia (SA) and preoperative risk factors, maternal anesthesia complications, and neonatal outcomes following cesarean delivery in Africa are unknown.

METHODS:
This is a secondary explanatory analysis of 3792 patients undergoing cesarean delivery in ASOS, a prospective observational cohort study, across 22 African countries. The primary aim was to estimate the association between preoperative risk factors and the outcome of the method of anesthesia delivered. Secondary aims were to estimate the association between the method of anesthesia and the outcomes (1) maternal intraoperative hypotension, (2) severe maternal anesthesia complications, and (3) neonatal mortality. Generalized linear mixed models adjusting for obstetric gravidity and gestation, American Society of Anesthesiologists (ASA) category, urgency of surgery, maternal comorbidities, fetal distress, and level of anesthesia provider were used.

RESULTS:
Of 3709 patients, SA was performed in 2968 (80%) and GA in 741 (20%). Preoperative factors independently associated with GA for cesarean delivery were gestational age (adjusted odds ratio [aOR], 1.093; 95% confidence interval [CI], 1.052–1.135), ASA categories III (aOR, 11.84; 95% CI, 2.93–46.31) and IV (aOR, 11.48; 95% CI, 2.93–44.93), eclampsia (aOR, 3.92; 95% CI, 2.18–7.06), placental abruption (aOR, 6.23; 95% CI, 3.36–11.54), and ruptured uterus (aOR, 3.61; 95% CI, 1.36–9.63). SA was administered to 48 of 94 (51.1%) patients with eclampsia, 12 of 28 (42.9%) with cardiac disease, 14 of 19 (73.7%) with preoperative sepsis, 48 of 76 (63.2%) with antepartum hemorrhage, 30 of 55 (54.5%) with placenta previa, 33 of 78 (42.3%) with placental abruption, and 12 of 29 (41.4%) with a ruptured uterus. The composite maternal outcome “all anesthesia complications” was more frequent in GA than SA (9/741 [1.2%] vs 3/2968 [0.1%], P < .001). The unadjusted neonatal mortality was higher with GA than SA (65/662 [9.8%] vs 73/2669 [2.7%], P < .001). The adjusted analyses demonstrated no association between method of anesthesia and (1) intraoperative maternal hypotension and (2) neonatal mortality.

CONCLUSIONS:
Analysis of patients undergoing anesthesia for cesarean delivery in Africa indicated patients more likely to receive GA. Anesthesia complications and neonatal mortality were more frequent following GA. SA was often administered to high-risk patients, including those with eclampsia or obstetric hemorrhage. Training in the principles of selection of method of anesthesia, and the skills of safe GA and neonatal resuscitation, is recommended.