The Lancet Global Health (Apr 2019)

Maternal and neonatal outcomes after caesarean delivery in the African Surgical Outcomes Study: a 7-day prospective observational cohort study

  • David Bishop, PhD,
  • Robert A Dyer, ProfPhD,
  • Salome Maswime, PhD,
  • Reitze N Rodseth, ProfPhD,
  • Dominique van Dyk, FCA,
  • Hyla-Louise Kluyts, ProfMMed Anaes,
  • Janat T Tumukunde, MMed Anaes,
  • Farai D Madzimbamuto, FCA ECSA,
  • Abdulaziz M Elkhogia, FRCA,
  • Andrew K N Ndonga, FICS,
  • Zipporah W W Ngumi, ProfFFARCS,
  • Akinyinka O Omigbodun, ProfFWACS,
  • Simbo D Amanor-Boadu, ProfFMCA,
  • Eugene Zoumenou, ProfPhD,
  • Apollo Basenero, MBChB,
  • Dolly M Munlemvo, MD,
  • Coulibaly Youssouf, ProfMD,
  • Gabriel Ndayisaba, ProfMD,
  • Akwasi Antwi-Kusi, FGCS,
  • Veekash Gobin, MD,
  • Patrice Forget, ProfMD,
  • Bernard Mbwele, MSc,
  • Henry Ndasi, DS,
  • Sylvia R Rakotoarison, MD,
  • Ahmadou L Samateh, FWACS,
  • Ryad Mehyaoui, ProfMD,
  • Ushmaben Patel-Mujajati, MMed Anaes,
  • Chaibou M Sani, MD,
  • Tonya M Esterhuizen, MSc,
  • Thandinkosi E Madiba, ProfPhD,
  • Rupert M Pearse, ProfMD Res,
  • Bruce M Biccard, ProfPhD,
  • Hippolyte Abadagan,
  • N Abbas,
  • A Ibrahim Abdelatif,
  • Traoré Abdoulaye,
  • A Abd-rouf,
  • A Abduljalil,
  • A Abdulrahman,
  • S Abdurazig,
  • A Abokris,
  • W Abozaid,
  • SOA Abugassa,
  • F Abuhdema,
  • SA Abujanah,
  • R Abusamra,
  • A Abushnaf,
  • SA Abusnina,
  • TS Abuzalout,
  • HM Ackermann,
  • YB Adamu,
  • A Addanfour,
  • DM Adeleke,
  • TA Adigun,
  • AO Adisa,
  • Sèhivè Valéry Adjignon,
  • NA Adu-Aryee,
  • BB Afolabi,
  • AFX Agaba,
  • PKA Agaba,
  • K Aghadi,
  • H Agilla,
  • B Ahmed,
  • El-Z Ahmed,
  • Al-J Ahmed,
  • M Ahmed,
  • Rene Ahossi,
  • SA Aji,
  • S Akanyun,
  • I Akhideno,
  • M Akhter,
  • OA Akinyemi,
  • M Akkari,
  • Joseph Akodjenou,
  • AL AL Samateh,
  • ES al Shams,
  • OT Alagbe-Briggs,
  • EA Alakkari,
  • RB Alalem,
  • M Alashhab,
  • OI Alatise,
  • A Alatresh,
  • MSI Alayeb Alayeb,
  • BA Albakosh,
  • F Albert,
  • ANJD Alberts,
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  • A Alfari,
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  • HA Algedar,
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  • FFH Alhoty,
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  • YA Ali,
  • A Ali,
  • Beye Seïdina Alioune,
  • MA Alkassem,
  • MA Alkchr,
  • TS Alkesa,
  • A Alkilani,
  • F Alkobty Alkobty,
  • Thomas Allaye,
  • SBM Alleesaib,
  • A Alli,
  • K Allopi,
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  • A Almajbery,
  • R Almesmary,
  • SHA Almisslati,
  • F Almoraid,
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  • Christella S Alphonsus,
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  • LM Ford,
  • Patrice Forget,
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Journal volume & issue
Vol. 7, no. 4
pp. e513 – e522

Abstract

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Summary: Background: Maternal and neonatal mortality is high in Africa, but few large, prospective studies have been done to investigate the risk factors associated with these poor maternal and neonatal outcomes. Methods: A 7-day, international, prospective, observational cohort study was done in patients having caesarean delivery in 183 hospitals across 22 countries in Africa. The inclusion criteria were all consecutive patients (aged ≥18 years) admitted to participating centres having elective and non-elective caesarean delivery during the 7-day study cohort period. To ensure a representative sample, each hospital had to provide data for 90% of the eligible patients during the recruitment week. The primary outcome was in-hospital maternal mortality and complications, which were assessed by local investigators. The study was registered on the South African National Health Research Database, number KZ_2015RP7_22, and on ClinicalTrials.gov, number NCT03044899. Findings: Between February, 2016, and May, 2016, 3792 patients were recruited from hospitals across Africa. 3685 were included in the postoperative complications analysis (107 missing data) and 3684 were included in the maternal mortality analysis (108 missing data). These hospitals had a combined number of specialist surgeons, obstetricians, and anaesthetists totalling 0·7 per 100 000 population (IQR 0·2–2·0). Maternal mortality was 20 (0·5%) of 3684 patients (95% CI 0·3–0·8). Complications occurred in 633 (17·4%) of 3636 mothers (16·2–18·6), which were predominantly severe intraoperative and postoperative bleeding (136 [3·8%] of 3612 mothers). Maternal mortality was independently associated with a preoperative presentation of placenta praevia, placental abruption, ruptured uterus, antepartum haemorrhage (odds ratio 4·47 [95% CI 1·46–13·65]), and perioperative severe obstetric haemorrhage (5·87 [1·99–17·34]) or anaesthesia complications (11·47 (1·20–109·20]). Neonatal mortality was 153 (4·4%) of 3506 infants (95% CI 3·7–5·0). Interpretation: Maternal 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. Funding: Medical Research Council of South Africa.