Maternal and Perinatal Mortality and Complications Associated With Cesarean Delivery in Low-Income and Middle-Income Countries: A Systematic Review and Meta-analysis

Around the world every year, 300,000 women die during childbirth, with 99% of these cases occurring in low- and middleincome countries (LMICs). One potential cause is accessibility to cesarean deliveries in these countries, which are both overutilized and underutilized and contribute to maternal and perinatal adverse outcomes. Previous studies have not provided precise estimates on maternal and offspring deaths after cesarean deliveries in LMICs, have had small study sizes, used modeled data with assumptions, or not truly evaluated perinatal outcomes in these scenarios. The researchers wanted to identify the key maternal and perinatal risk factors after cesarean deliveries in LMICs, as well as the morbidity and mortality in these patients. Performing a systematic review and meta-analysis, the researchers searched 6 databases from January 1990 through November 2017 for studies that reported on maternal or perinatal death after cesarean deliveries in LMICs. Studies excluded took place in high-income countries, those with nonpregnant women, and case reports and studies published before 1990. The prevalence of maternal mortality in LMICs for women undergoing cesarean deliveries was the main outcome. A randomeffects model was used to calculate the rate data, and the odds ratios with 95% confidence intervals were used to report the association between risk factors and outcomes. From 67 LMICs, 196 studies met inclusion criteria.Of the 116 studies that reported onmaternal death risk after cesarean delivery, 50 were from low-income countries, 64 frommiddle-income countries, and 2 were fromWorld Health Organization (WHO) multiregion studies. Sub-Saharan Africa was the area most studied, representing 87 of the studies (76%) and also represented the highest risk of maternal death after cesarean delivery (10.9 per 1000 procedures) compared with the risk with all 116 studies (7.6 per 1000 procedures). In 72 studies, a quarter of all women who died in LMICs (27,651 deaths) had a cesarean delivery performed (23.8%). The researchers concluded that the rate of maternal and perinatal deaths after cesarean deliveries was high in LMICs compared with the rest of the world, proportionally 100 times higher than the rate in high-income countries (8 deaths per 100,000 cesarean deliveries). It has not been reduced over the past 30 years, and the worst outcomes occur more frequently in countries with a low rate of cesarean deliveries. For women undergoing cesarean deliveries, failure of labor progression and history of previous cesarean delivery were the most common indications, and postpartum hemorrhage was the main cause of death. The researchers acknowledge that their findingswere limited by population differences, study differences, and that few of the identified studies were from Europe, Central Asia, the Middle East, and Northern Africa.