Making caesarean section safer for African mothers
Authors: Anna J Dare
Journal: The Lancet Global Health (2019)

In many African countries, women giving birth still face substantial risks to their own life and that of their baby. In this issue of The Lancet Global Health, David Bishop and colleagues1Bishop D Dyer RA Maswime S et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar report on maternal and neonatal outcomes after caesarean section in 22 African countries. Their findings suggest that this risk remains true even for women who have access to caesarean delivery in a hospital facility, the highest level of intervention afforded under emergency obstetric care. The 3792 women who had a caesarean section in 2016 form a nested cohort within the African Surgical Outcomes Study (ASOS)—a large prospective observational study of surgical volume and outcomes on the continent that employed a 7-day snapshot data capture method.2Biccard BM Madiba TE Kluyts HL et al.Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet. 2018; 391: 1589-1598Summary Full Text Full Text PDF PubMed Scopus (285) Google Scholar Over three-quarters of women having caesarean delivery presented emergently, with a high baseline preoperative risk owing to pregnancy-related complications, including pre-eclampsia or eclampsia, placenta praevia, placental abruption, uterine rupture, and antepartum haemorrhage. The study mortality rate after caesarean delivery was 0·5% (95% CI 0·3–0·8), with a maternal mortality rate of 5·43 per 1000 operations—some 50 times higher than in high-income countries. Preoperative major bleeding risk, perioperative haemorrhage, and anaesthesia-related complications (a composite of failed intubation, aspiration, cardiac arrest, and hypoxia) were independently associated with mortality. One in six women developed a perioperative complication, with postpartum haemorrhage being the most common severe complication. Overall neonatal mortality after caesarean section was 4·4% (3·7–5·0), rising to 18·0% for infants delivered at 35 weeks or less gestational age. The study did not capture the overall number of deliveries at each participating hospital, so it is not possible to ascertain the caesarean section rate. However, in many African countries the reported caesarean section rate remains as low as 2–4%,3Boerma T Ronsmans C Melesse DY et al.Global epidemiology of use of and disparities in caesarean sections.Lancet. 2018; 392: 1341-1348Summary Full Text Full Text PDF PubMed Scopus (593) Google Scholar much lower than the 10–19% rate associated with improved maternal and neonatal outcomes at the population level.4Molina G Weiser TG Lipsitz SR et al.Relationship between cesarean delivery rate and maternal and neonatal mortality.JAMA. 2015; 314: 2263-2270Crossref PubMed Scopus (330) Google Scholar, 5Ye J Zhang J Mikolajczyk R Torloni MR Gulmezoglu AM Betran AP Association between rates of caesarean section and maternal and neonatal mortality in the 21st century: a worldwide population-based ecological study with longitudinal data.BJOG. 2016; 123: 745-753Crossref PubMed Scopus (211) Google Scholar For the most part, the study cohort were young, had low parity, were healthy before pregnancy, and delivered term infants. As the authors acknowledge,1Bishop D Dyer RA Maswime S et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar owing to the non-representative sampling strategy used, a disproportionate number of participating centres were university-affiliated hospitals providing regionalised or specialised level care, rather than district hospitals, which act as first-level hospital providers of comprehensive emergency obstetric care for most African women (and typically with fewer resources).6Meara JG Leather AJ Hagander L et al.Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (1818) Google Scholar Two-thirds of patients were from middle-income countries, where access to maternal and neonatal care, including trained obstetric and anaesthesia providers, is on average much better than in Africa's poorest countries. The true morbidity and mortality after caesarean section on the continent is therefore likely to be higher than reported. One of the major challenges with studying maternal mortality after caesarean section with a 7-day data snapshot method is that death is an infrequent outcome (20 deaths of 3792 caesarean sections), even in countries with high rates by global standards. Pooling deaths across health facilities and countries to achieve stable continental-wide estimates and to identify explanatory variables comes at the expense of the contextual granularity required to understand the root causes of each maternal death within a given facility and country. Both approaches are ultimately needed to document the magnitude of the problem and to identify which deaths and complications after caesarean section occur as a result of poor-quality care or failure to rescue and are attributable to processes occurring within the health facility, and which represent shortcomings in the broader health system. An example of the latter would be prehospital delays that result in presentations too late to significantly change the trajectory of the outcome even in the presence of high-quality emergency obstetric care. Despite these limitations, two areas clearly stand out from the study findings as promising intervention points and are well supported by other analyses.7Sobhy S Zamora J Dharmarajah K et al.Anaesthesia-related maternal mortality in low-income and middle-income countries: a systematic review and meta-analysis.Lancet Glob Health. 2016; 4: e320-e327Summary Full Text Full Text PDF PubMed Scopus (91) Google Scholar, 8Uribe-Leitz T Jaramillo J Maurer L et al.Variability in mortality following caesarean delivery, appendectomy, and groin hernia repair in low-income and middle-income countries: a systematic review and analysis of published data.Lancet Glob Health. 2016; 4: e165-e174Summary Full Text Full Text PDF PubMed Scopus (50) Google Scholar The first is the crucial need for safe obstetric anaesthesia in sub-Saharan Africa. In the present study,1Bishop D Dyer RA Maswime S et al.Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet Glob Health. 2019; 7: e513-e522Summary Full Text Full Text PDF PubMed Scopus (100) Google Scholar 10% of deaths after caesarean section were attributable to anaesthesia-related complications, which are almost always preventable. The consistent use of surgical safety checklists in the operating room (used in only half of all caesarean sections in the present study) and the availability of pulse oximetry and appropriate monitoring for both spinal and general anaesthesia are low-cost interventions that facilitate early identification and correction of potential perioperative complications, including bleeding. Dedicated training in anaesthesia is important for treating the obstetric patient, whose airway and physiology can present unique challenges, as is ensuring appropriate supervision and support, especially in emergencies, for non-physician anaesthesia providers who in the present study provided 25% of obstetric anaesthesia care. The second area for focused intervention is the management of bleeding risk and postpartum haemorrhage in obstetric surgical patients. The routine availability of blood products is a major challenge in many low-income and middle-income countries6Meara JG Leather AJ Hagander L et al.Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (1818) Google Scholar and, in the face of substantial perioperative bleeding, undoubtedly contributes to failure to rescue and maternal-fetal demise. Early identification of patients at risk of bleeding and their active management with the use of WHO-recommended strategies, such as the administration of uterotonic drugs and cord traction to remove the placenta, might reduce the risk of postpartum haemorrhage and the need for blood products. Similarly, early administration after delivery of the antifibrinolytic drug tranexamic acid reduces maternal deaths due to bleeding,9WOMAN Trial CollaboratorsEffect of early tranexamic acid administration on mortality, hysterectomy, and other morbidities in women with post-partum haemorrhage (WOMAN): an international, randomised, double-blind, placebo-controlled trial.Lancet. 2017; 389: 2105-2116Summary Full Text Full Text PDF PubMed Scopus (719) Google Scholar although the evidence in direct support of this outcome for postpartum haemorrhage was published after the study closed. Despite persistently low reported caesarean section rates in sub-Saharan Africa, caesarean section was still the most common surgical procedure performed in the larger ASOS cohort, making up a third of all operative procedures.2Biccard BM Madiba TE Kluyts HL et al.Perioperative patient outcomes in the African Surgical Outcomes Study: a 7-day prospective observational cohort study.Lancet. 2018; 391: 1589-1598Summary Full Text Full Text PDF PubMed Scopus (285) Google Scholar This finding is in keeping with other studies of surgical volume on the continent.6Meara JG Leather AJ Hagander L et al.Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (1818) Google Scholar As such, a strong argument can be made for coordinated efforts to improve and standardise the quality of care around caesarean delivery, while simultaneously working to improve access. The Lancet Commission on Global Surgery6Meara JG Leather AJ Hagander L et al.Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development.Lancet. 2015; 386: 569-624Summary Full Text Full Text PDF PubMed Scopus (1818) Google Scholar identified the availability of caesarean section as a bellwether procedure, predictive of the ability of a first-level hospital provider to deliver a range of life-saving obstetric and non-obstetric surgical procedures. In a similar manner, improving the quality of care for women having caesarean delivery could have an effect on a range of surgical procedures delivered at a given health facility. Substantial progress has been made over the past 20 years in reducing maternal mortality, including in Africa, yet global disparities persist across all levels of obstetric care. As the present study highlights, making childbirth safer for African mothers will require dedicated efforts to make caesarean section much safer as well. This improvement in safety must occur while simultaneously striving to avoid the overuse of caesarean section, which many other countries are now grappling with. I declare no competing interests. Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort studyMaternal mortality after caesarean delivery in Africa is 50 times higher than that of high-income countries and is driven by peripartum haemorrhage and anaesthesia complications. Neonatal mortality is double the global average. Early identification and appropriate management of mothers at risk of peripartum haemorrhage might improve maternal and neonatal outcomes in Africa. Full-Text PDF Open Access