An analysis of the practices of caesarean section in sub-Saharan Africa: A summary of the literature

Introduction: Ensuring access to quality caesarean sections (CS) is a challenge for the next millennium and a sustainable development goal to reduce maternal and infant mortality. A CS involves risks and complications and should therefore be performed in an approved way and not used excessively. The WHO recommends that the CS rate should not exceed 10–15%. Approximately 99% of maternal deaths occur in developing countries where efforts to reduce maternal deaths are still low. This review of the literature aims to provide a summary of CS practices in sub-Saharan Africa and the consequences in terms of morbidity and mortality.

Material and Method: The data was collected following the selection criteria on the NCBI’s PubMed.

Result: Across the four main themes selected for this summary, the frequency of CS varies from 2 to 51%. Indications for caesarean CS are mainly dystocia, foetal distress, scarred uterus, breech presentation, antenatal haemorrhage and hypertensive disorders. Maternal risks related to CS are surgical site infections, obstetric fistulae, anaesthetic complications, pulmonary embolism, postpartum haemorrhage, haemostatic hysterectomy and maternal death, and the perinatal risks related to CS are respiratory distress, prematurity and perinatal death.

Conclusion: In the current working conditions, the risks incurred by the mother and the foetus during a CS are significantly greater than during a vaginal delivery. CS is not yet a factor in reducing maternal and perinatal morbidity and mortality in Sub-Saharan Africa. To reduce maternal and perinatal morbidity and mortality, working conditions at referral centre level, transfer conditions, and improve the training of health staff should be improved.

Introduction

A caesarean section (CS) is a major procedure in the management of complications during pregnancy and labour. In countries in the Global South, it accounts for the vast majority of obstetric interventions regardless of whether the indication is absolute, necessary or prudent. Ensuring quality access to CS is a key challenge for the millennium [1], and the next sustainable development goal to reduce maternal and infant mortality. As with any surgical procedure, a CS involves risks and complications and should therefore be performed in an approved way and not used excessively. Although the optimum CS at population level is difficult to assess, the World Health Organization (WHO) recommends that the national CS rate should not exceed 10% to 15% [2]; however, in many countries, the CS rate is rising [3]. Studies on the relationship between the CS rate and maternal and perinatal mortality and morbidity have concluded contradictory results [4-8]. Maternal mortality has a significant impact on the surviving family, the broader community, healthcare providers and society in general. It is also frequently used as a regional or national public health indicator to assess a healthcare system’s quality. Nearly 300,000 women die every year as a result of a pregnancy or a CS or vaginal delivery. Approximately 99% of these deaths occur in developing countries [9]. Systemic action is therefore needed to reduce maternal mortality. These efforts are real but remain insufficient, particularly in the Democratic Republic of the Congo (DRC), which is among the sub-Saharan African countries making the slowest progress in combating maternal mortality [10].

The goal of this systematic review of the literature is to provide a summary of CS practices in sub-Saharan Africa and of the consequences in terms of morbidity and mortality. It looks successively at the CS rate, its indications and the consequences of the practice in terms of maternal and perinatal mortality and morbidity.

Materials and Method

References were selected based on the following criteria: the type of study on CS, the target population and the data analysis using the following search terms on PubMed (intra-operative complications, caesarean section, maternal mortality and morbidity, perinatal mortality and morbidity, Africa South of the Sahara) for the period from 2011 to 2016 (the period during which we started missions to support the training of gynaecologists and obstetricians in the east of the Democratic Republic of the Congo).

The following inclusion criteria were applied: articles focusing essentially on the CS, the indications for a CS, and maternal and perinatal complications associated with CS in sub-Saharan Africa. The studies selected were retrospective, prospective, clinical trials and ecological studies. Clinical cases were excluded from this review.

The target population is the population of sub-Saharan Africa: the population studied was composed of women who had a CS delivery and their new-borns infants. The registrations of the participants involved in the various studies were examined along with the outcomes according to the indications for CS, post-operative complications, and maternal and perinatal mortality. The following keywords were used: intra-operative complications, caesarean section, maternal mortality and morbidity, perinatal mortality and morbidity, indications, frequency and caesarean section, Africa South of the Sahara.

The criteria for excluding articles were: absence of data and worthwhile results, absence of information on the chosen themes, clinical cases, and articles published outside the period under study.

Results

This data was obtained after searching on PubMed in English using the keywords. 570 citations were found, 165 of which were summary articles during the five years. Some of these articles did not meet the selection criteria and were therefore not used (maternal and neonatal morbidity and mortality associated with CS, indications, and CS frequency); ultimately, 68 scientific articles were used.

Figure 1. Flowchart for the selection of the articles included in the review

Figure 1: Flowchart of 68 selected articles.

For the four key themes in this summary, 68 articles were selected and analysed based on the type of study, the target population, keywords and the data analysis.

Table 1. Caesarean frequency in sub-Saharan Africa varies from 2 to 51% [4,10-42].

Table 2. The main indications for caesarean section described by these authors are: a previous CS or scarred uterus, dystocia, foetal distress, breech presentation, antenatal haemorrhage (haemorrhagic placenta praevia, abruption of a normally positioned placenta) and pregnancy-related hypertensive disorders [10,16,21,33,38,43-47].

Table 3. The main maternal post-operative complications associated with caesarean sections are: surgical site infections, obstetric fistulae, pulmonary embolism, postpartum haemorrhage, maternal death, and the peroperative complications are anaesthetic complications, complicated haemorrhage in haemostatic hysterectomy and maternal death [10,15,16,19,21,28,33,37-39,45,48-62].

Table 4. The main perinatal complications are: respiratory distress, prematurity and perinatal death [12,63-75].

Discussion

Caesarean frequency: The CS rate seen in this systematic review of the literature varies between 2 and 51%. Indeed, in 1985, a group of WHO experts concluded that there was ‘no justification for any region in the world to have a CS rate higher than 10 to 15% [76,77], It is important to note that these recommendations from the WHO are particularly valid for planned CS, the rate of which should be very low except in centres that handle high-risk pregnancies. The study by Briand [18], unfortunately shows that there are more emergency CS than elective CS performed in developing countries, which results in an increase in maternal and perinatal complications. Although a CS is an effective technique for preventing maternal and perinatal mortality when used appropriately, it is not free of risk and is associated with short- and long-term complications [6]. In our review, pregnancy-related hypertensive disorders, especially pre-eclampsia, foetal distress, antenatal haemorrhage (placenta praevia, abruption of a normally positioned placenta) lead to an increase in the CS rate and in the maternal and perinatal risks [11,12]. In sub-Saharan Africa, a high CS rate is associated with an increase in maternal and perinatal mortality and morbidity [13], however, the 2% rate is related to lack of access to CS for most of the women in the population group studied [15], (lack of transport infrastructure, lack of local centres, lack of financial means among the population). Most CS are performed during labour and more specifically in the second stage (between 4 cm and full dilation), which leads to an increase in maternal and perinatal complications [16,18]. The CS rate is increasing in certain developed countries because this intervention is associated with low maternal risk when combined with proper use of anaesthesia, blood transfusion, antibiotics and a safe surgical technique. It does not lead to an increase in maternal mortality and prevents possible medicolegal problems associated with foetal distress. However, in developing countries, excessive use of CS increases maternal mortality. In these countries, neonatal mortality increases in line with maternal mortality. In order to decrease maternal mortality, we should promote access to CS for all women who need one, improve the quality of the intervention and avoid its excessive use.

The main indications for a CS are a previous CS or scarred uterus, dystocia, foetal distress, breech presentation, antenatal haemorrhage (haemorrhagic placenta praevia, abruption of a normally positioned placenta) and pregnancy-related hypertensive disorders [10,16,21,33,38,43-47]. The ‘once a CS always a CS’ policy is widely applied in sub-Sahara Africa, mainly from fear of uterine rupture during labour. This policy helps reduce both the uterine rupture rate and the emergency surgery responsible for the increase in maternal and perinatal mortality and morbidity. These repeat CS do not, however, result in the medical benefits expected. In fact, a vaginal delivery after a CS has a low risk both for the mother and for the child. Although the International Federation of Gynecology and Obstetrics (IFGO) has published guidelines promoting vaginal delivery after a CS [78], fewer women are having vaginal deliveries in referral hospitals in sub-Saharan Africa. After analysing these indications, dystocia (difficult and protracted labour) was the main indication for the first CS. Dystocia is mainly caused by insufficient uterine contractions, sometimes by cephalopelvic disproportion, no progress in foetal descent due to a tumour, and abnormal presentation of the foetus.

However, lack of resources and qualified staff sometimes makes this diagnosis difficult prior to labour. It is possible that dystocia is currently being over-diagnosed in order to warrant greater use of CS [10]. Use of partographs to assess the eutocic or dystocic progress of labour is very low [70].

Breech presentation (buttocks or feet) accounts for approximately 3.5% of all births [79]. When parameters are properly monitored, caesarean CS have not always resulted in the best outcomes in relation to a vaginal breech birth. The freer use of CS for breech presentation in sub-Saharan Africa has led to an increase in maternal mortality and morbidity and in potential risks for future pregnancies [47]. The use of external cephalic version (ECV) has attracted interest in reducing breech presentations. In developing countries, due to lack of selection criteria for vaginal or CS breech births, ECV is not widely practiced, and this leads to an increase in perinatal morbidity and mortality [79]. It is, however, worthwhile, but screening for complications of the procedure, particularly acute distress, requires foetal monitoring equipment (ultrasound, monitors, emergency delivery room) that is very rarely available due to lack of resources. Foetal distress is one of the main indications for CS in this review of the literature. Foetal distress is indicated by a change in foetal heart rhythm and this means that the foetus is not receiving sufficient oxygen via the placenta. Lack of oxygen, or hypoxia, can cause foetal death and brain damage. As with dystocia, there were doubts over the accuracy of this diagnosis. The study by Ajah et al. on foetal monitoring was unable to show an improvement in the infants’ well-being parameters in relation to the use of a Pinard stethoscope [12]. However, this study shows an increase in the use of CS when monitoring was used, because it is difficult to make the distinction between foetal stress and true distress [80]. The less training staff have had in foetal monitoring, the higher the false positive rate. As such, more than half of the diagnoses of foetal distress are inappropriate. In developed countries, use of STAN (ST segment analysis) has reduced the rate of false diagnosis of foetal distress. Unfortunately, its use in sub-Saharan Africa is practically non-existent [81]. Antenatal haemorrhage (placenta praevia, abruption of a normally positioned placenta) is a common indication for CS in our study. Unfortunately, it is often unavoidable and increases maternal and perinatal mortality and morbidity.

In our study, the CS risks for the mother are infections, anaesthetic risks, pulmonary embolism, postpartum haemorrhage, haemostatic hysterectomy, obstetric fistulae and maternal death. While a CS is currently safer in developed countries, it still entails the risks of many major abdominal procedures in sub-Saharan Africa. Maternal mortality after CS is 2 to 11 times higher than after a vaginal delivery [62]. Maternal morbidity associated with CS is 5 to 10 times higher than with vaginal deliveries. As the prevalence of uterine rupture increases in the event of protracted labour and a previous CS, studying the maternal risk factors can help prevent these complications [48,49]. Performing a CS during the second stage of labour increases the risk of complications. Anticipating the diagnosis of dyskinesia should make it possible to remove the foetus earlier and therefore reduce those risks [16]. Haemorrhagic and infectious complications are frequently seen due to lack of asepsis in the operating theatre as well as due to insufficient surgical training [33,59]. Improving the quality of CS is necessary to reduce maternal and perinatal complications in sub-Saharan Africa.

The main perinatal complications seen in our study are prematurity, respiratory distress and perinatal death. Elective CS account for approximately 9% of neonatal intensive care admissions. This rate increases in the event of an emergency CS. The main cause for admissions to the neonatal unit is lung disease due to complicated iatrogenic prematurity, primarily hyaline membrane disease or infant respiratory distress syndrome, due to pulmonary immaturity [32]. Due to lack of an adequate resuscitation service, CS in sub-Saharan Africa increase the perinatal risks. It is important to wait for pulmonary maturity before performing elective or repeat CS in order to prevent respiratory distress syndrome. However, infants born via elective CS account for more cases of this syndrome [32]. The factor that leads to respiratory diseases in infants born via CS before labour is the absence of catecholamine secretions (stress hormone) which are normally released by uterine contractions during labour [32]. Babies born via elective CS before labour have low levels of catecholamine after the birth compared with babies born via vaginal delivery. The other risks for the child after a CS are less frequent and are estimated at approximately 0.4% of birth trauma in children born via CS, such as lacerations. General anaesthetic causes respiratory depression especially if the intervention is long. Local anaesthetic does not cause hypoxia, but does cause maternal hypotension.

Proper training of gynaecologists, anaesthetists and midwives is essential in order to decrease these complications.

Conclusions

In the current working conditions in sub-Saharan Africa, the risks to the mother and foetus during a CS are significantly greater than during a vaginal delivery. The high maternal and perinatal morbidity and mortality rate during and after a CS is associated with a number of factors such as the indication for CS, the conditions of the intervention, the period between indication and intervention, particularly in the case of transfers, insufficient resuscitation equipment, as well as the quality and continuity of pre-, per- and post-operative care. The foeto-maternal prognosis, therefore, depends on the quality of the transfer and their management, the quality of care, and the population’s level of understanding of health problems. CS is not yet a factor in reducing foeto-maternal morbidity and mortality. The different results reflect the inefficiency of the referral system for quality obstetric care. CS should be a factor in reducing foeto-maternal morbidity and mortality by improving the transfer conditions, the working conditions at referral centre level and the training of health staff. In order to help clarify the grey areas and to implement appropriate interventions, it is desirable to carry out a periodic audit to assess the quality of obstetric and neonatal care in countries where maternal mortality is high.

Author comments

This review of the literature discusses the higher maternal and perinatal mortality and morbidity in CS in relation to vaginal deliveries. This seems normal given that the CS were performed after diagnosis of often life-threatening complications. Anticipating these complications would help reduce excessive use of CS and to assess the effectiveness of the obstetrics team. Monitoring the foetal heart rhythm with continuous recording is more reliable than intermittent monitoring using a Pinard stethoscope, and greater awareness of the criteria for defining the external and internal foetal monitoring graphs makes it possible to diagnose foetal distress. In the majority of cases, training staff to correctly interpret monitoring is essential.

Although we here demonstrated CS percentage and characterized conditions related to CS in this area, we cannot answer the question 1) what percentage is the “adequate” for CS in this area, and 2) whether CS itself (surgery itself) ameliorate or deteriorate materno-neonatal mortality/morbidity. CS should be performed under an appropriate indication, at an appropriate timing and conditions. It also requires before and after care of the surgery. In this area, these are considered not well done. Therefore, it is impossible to conclude whether CS itself or non-employment of CS itself relates with the outcome. In short, CS in developed countries and CS in developing countries (like here) is difficult to compare. We understand this, and still we believe that reporting these data is important as a basic data for making better health policy regarding materno-neonatal health promotion, including CS.

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