Objective In the context of rapid changes regarding practices related to delivery in Africa, we assessed maternal and perinatal adverse outcomes associated with the mode of delivery in 41 referral hospitals of Mali and Senegal. Study Design Cross-sectional survey nested in a randomised cluster trial (1/10/2007–1/10/2008). The associations between intended mode of delivery and (i) in-hospital maternal mortality, (ii) maternal morbidity (transfusion or hysterectomy), (iii) stillbirth or neonatal death before Day 1 and (iv) neonatal death between 24 hours after birth and hospital discharge were examined. We excluded women with immediate life threatening maternal or fetal complication to avoid indication bias. The analyses were performed using hierarchical logistic mixed models with random intercept and were adjusted for women's, newborn's and hospitals' characteristics. Results Among the 78,166 included women, 2.2% had a pre-labor cesarean section (CS) and 97.8% had a trial of labor. Among women with a trial of labor, 87.5% delivered vaginally and 12.5% had intrapartum CS. Pre-labor CS was associated with a marked reduction in the risk of stillbirth or neonatal death before Day 1 as compared with trial of labor (OR = 0.2 [0.16–0.36]), though we did not show that maternal mortality (OR = 0.3 [0.07–1.32]) and neonatal mortality after Day 1 (OR = 1.3 (0.66–2.72]) differed significantly between groups. Among women with trial of labor, intrapartum CS and operative vaginal delivery were associated with higher risks of maternal mortality and morbidity, and neonatal mortality after Day 1, as compared with spontaneous vaginal delivery. Conclusions In referral hospitals of Mali and Senegal, pre-labor CS is a safe procedure although intrapartum CS and operative vaginal delivery are associated with increased risks in mothers and infants. Further research is needed to determine what aspects of obstetric care contribute to a delay in the provision of intrapartum interventions so that practices may be made safer when they are needed.
References
[1]
Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, et al. (2007) Maternal and neonatal individual risks and benefits associated with cesarean delivery: multicentre prospective study. BMJ 335(7628): 1025.
[2]
Deneux-Tharaux C, Carmona E, Bouvier-Colle MH, Breart G (2006) Postpartum maternal mortality and cesarean delivery. Obstet Gynecol 108(3 Pt 1): 541–548.
[3]
Kamilya G, Seal SL, Mukherji J, Bhattacharyya SK, Hazra A (2010) Maternal mortality and cesarean delivery: an analytical observational study. J Obstet Gynaecol Res 36(2): 248–253.
[4]
Clark SL, Belfort MA, Dildy GA, Herbst MA, Meyers JA, et al. (2008) Maternal death in the 21st century: causes, prevention, and relationship to cesarean delivery. Am J Obstet Gynecol 199(1) 36: e1–5.
[5]
Fournier P, Dumont A, Tourigny C, Dunkley G, Dramé S (2009) Improved access to comprehensive emergency obstetric care and its effect on institutional maternal mortality in rural Mali. Bull World Health Organ 87(1): 30–38.
[6]
Fenton PM, Whitty CJ, Reynolds F (2003) Cesarean section in Malawi: prospective study of early maternal and perinatal mortality. BMJ 327(7415): 587.
[7]
Hussein J, Goodburn EA, Damisoni H, Lema V, Graham W (2001) Monitoring obstetric services: putting the ‘UN Guidelines’ into practice in Malawi: 3 years on. Int J Gynaecol Obstet 75(1): 63–73.
[8]
Stanton CK, Holtz SA (2006) Levels and trends in cesarean birth in the developing world. Stud Fam Plann 37(1): 41–48.
[9]
Dumont A, Fournier P, Fraser W, Haddad S, Traore M, et al. (2009) QUARITE (quality of care, risk management and technology in obstetrics): a cluster-randomized trial of a multifaceted intervention to improve emergency obstetric care in Senegal and Mali. Trials 10: 85.
[10]
Villar J, Valladares E, Wojdyla D, Zavaleta N, Carroli G, et al. (2006) Cesarean delivery rates and pregnancy outcomes: the 2005 WHO global survey on maternal and perinatal health in Latin America. Lancet 367(9525): 1819–1829.
[11]
Ronsmans C, De Brouwere V, Dubourg D, Dieltiens G (2004) Measuring the need for life-saving obstetric surgery in developing countries. BJOG 111(10): 1027–1030.
[12]
Shah A, Fawole B, M'Imunya J M, Amokrane F, Nafiou I, et al. (2009) Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa. Int J Gynaecol Obstet 107(3): 191–197.
[13]
Molenberghs G, Verbeke G (2005) Models for Discrete Longitudinal Data. New York Springer.
[14]
Altman DG (1998) Confidence intervals for the number needed to treat. BMJ 317; 1309.
[15]
Lumbiganon P, Laopaiboon M, Gulmezoglu AM, Souza JP, Taneepanichskul S, et al. (2010) Method of delivery and pregnancy outcomes in Asia: the WHO global survey on maternal and perinatal health 2007–08. Lancet 375(9713): 490–499.
[16]
Souza JP, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, et al. (2010) Cesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004–2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med 8: 71.
[17]
Liu S, Liston RM, Joseph KS, Heaman M, Sauve R, et al. (2007) Maternal mortality and severe morbidity associated with low-risk planned cesarean delivery versus planned vaginal delivery at term. CMAJ 176(4): 455–460.
[18]
Allen VM, O'Connell CM, Liston RM, Baskett TF (2003) Maternal morbidity associated with cesarean delivery without labor compared with spontaneous onset of labor at term. Obstet Gynecol 102(3): 477–482.
[19]
De Luca R, Boulvain M, Irion O, Berner M, Pfister RE (2009) Incidence of early neonatal mortality and morbidity after late-preterm and term cesarean delivery. Pediatrics 123(6): e1064–1071.
[20]
MacDorman MF, Declercq E, Menacker F, Malloy MH (2008) Neonatal mortality for primary cesarean and vaginal births to low-risk women: application of an “intention-to-treat” model. Birth 35(1): 3–8.
[21]
Gregory KD, Jackson S, Korst L, Fridman M (2012) Cesarean versus vaginal delivery: whose risks? Whose benefits? Am J Perinatol 29(1): 7–18.
[22]
Hansen AK, Wisborg K, Uldbjerg N, Henriksen TB (2007) Pre-labor cesarean section and respiratory morbidity in the term and near-term neonate. Acta Obstet Gynecol Scand 86(4): 389–394.
[23]
Hofmeyr GJ, Hannah ME (2003) Planned cesarean section for term breech delivery. Cochrane Database Syst Rev (3): CD000166.
[24]
Campbell OM, Graham WJ (2006) Lancet Maternal Survival Series steering group (2006) Strategies for reducing maternal mortality: getting on with what works. Lancet 368(9543): 1284–1299.
[25]
Hofmeyr GJ, Haws RA, Bergstr？m S, Lee AC, Okong P, et al.. (2009) Obstetric care in low-resource settings: what, who, and how to overcome challenges to scale up? Int J Gynaecol Obstet 107 Suppl 1: S21–44, S44–45.
[26]
Alfirevic Z, Devane D, Gyte GM (2006) Continuous cardiotocography (CTG) as a form of electronic fetal monitoring (EFM) for fetal assessment during labour. Cochrane Database Syst Rev (3): CD006066.
