Caesarean sections (c-sections) are disproportionately threatening the lives of women and babies in low and middle-income countries, new research* finds.
The analysis of data from 12 million pregnancies, led by researchers at Queen Mary University, London, and published in The Lancet, finds that maternal deaths in low and middle-income countries (LMICs) are 100 times higher than in some high-income countries, and a third of all babies in some regions do not survive caesarean section.
First author Dr Soha Sobhy from Queen Mary University said: "To our knowledge, this is the largest and most comprehensive study to-date on the risks of death following caesarean section. The outcomes for women in low and middle-income countries are far worse than we expected.
"In sub-Saharan Africa, one in 100 women who has a caesarean section will die - 100 times more than women in the UK. The outcomes for their babies are even worse, with 8% not surviving longer than a week.”
Lead author Professor Shakila Thangaratinam from Queen Mary University, added: "Caesarean sections are the most commonly performed operation worldwide. They are meant to be life saving for both mother and baby, but because of many factors, such as poor access, late referrals, inappropriate procedures, poor resources and training, this is not always the case.
"Now that we know the risk factors and countries associated with poor outcomes, we can make a more targeted effort to improve conditions for mothers globally, so that timely and safe caesarean sections can be done wherever they are needed.”
Every year 300,000 women die during childbirth, 99% of which are from LMICs. Timely access to caesarean section when needed is required for safe childbirth, but procedures are being performed “too little, too late”, or “too many, too soon”, say the researchers.
The analysis looked at data from 196 studies from 67 LMICs, covering 12 million pregnancies. Findings included the fact that a quarter of all women in LMICs who died while giving birth had undergone caesarean section (23.8%). The risk of maternal death in women in LMICs undergoing caesarean section was 7.6 per 1,000 procedures - around 100-fold higher than the UK (8/100,000), and the highest burden was in sub-Saharan Africa (10.9/1,000). The overall rate of stillbirth in babies born by caesarean section was 56.6 per 1,000, with the highest rates in sub-Saharan Africa (82.5/1,000). The perinatal death rate was 84.7 per 1,000 caesarean sections, with the highest rates in Middle East and North Africa (354.6/1,000). Women who undergoing emergency caesarean section in LMICs were twice more likely to die than those delivering by elective caesarean section. The odds were increased 12-fold when caesarean section was performed in advanced labour at full dilatation of the cervix (second stage) than in the first stage.
Maternal death rates were particularly high in countries with very low caesarean section rates, highlighting the problems with too little access, too late.
Based on these findings, the researchers are calling on policy makers and healthcare professionals to improve access to surgery, promote appropriate use of the procedure, provide safe surgical environments, and increase neonatal resuscitation to help improve outcomes to babies.
The team also highlight that training in labour management needs to cover why caesarean sections are carried out, in order to reduce inappropriate caesarean sections, and promote a reduction in caesarean sections performed in the second stage of labour, which are the most risky.
The commonest cause of maternal death following caesarean section was postpartum haemorrhage, highlighting gaps in resource and skills to manage massive obstetric haemorrhage, and a need for specific training in this area.
Very few studies were published in some regions such as Europe and central Asia and Middle East and North Africa, and may affect the generalisability of the findings.
*Sobhy S, Arroyo-Manzano D, Murugesu N, et al. Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis. The Lancet, March 28, 2019. DOI:10.1016/S0140-6736(18)32386-9