Maternal and perinatal mortality and complications associated with caesarean section in low-income and middle-income countries: a systematic review and meta-analysis.
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Background Universal access to caesarean section is a key requirement for safe childbirth. We determined the burden of maternal and perinatal mortality and morbidity, and their risk factors following caesarean sections in low and middle-income countries (LMIC) by a systematic review. Methods We searched electronic databases until November 2017 without language restrictions for observational studies on maternal or perinatal outcomes following caesarean section in LMIC. We used random effects model to synthesise the rate data, and reported the association between risk factors and outcomes using odds ratios (OR) with 95% confidence intervals (CI). Findings We included 196 studies from 67 LMIC. The risk of maternal death in women undergoing caesarean section (116 studies, 2,933,456 caesarean section) was 7·6 per 1000 procedures (95% CI 6.6-8.5, Tau2=0.81); the highest burden was in sub-Saharan Africa (10·9/1000; 95% CI 9·5-12·5, Tau2=0·81). A quarter of all mothers who died in LMIC (72 studies, 27,651 deaths) had undergone caesarean section (23·8%, 95% CI 21·0-26·7). The rates of stillbirths and perinatal deaths in caesarean section births were 56.6 (95% CI 46.1-68.1, Tau2 = 1.33) and 84.7 / 1000 procedures (95% CI 70.5-100.2, Tau2 = 1.61) respectively. The odds of maternal death were increased for caesarean sections performed in the second vs. first stage of labour (OR 12·3; 95% CI 2·9 - 52·5, Tau2=0·0), and for emergency vs. elective caesarean section (OR 2·2; 95% CI 1·1 - 4·1, Tau2=0·91). Maternal mortality did not vary according to the type or experience of the operator. Interpretation: Maternal deaths and perinatal deaths following caesareans sections are disproportionately high in LMIC. The timing and urgency of caesarean section are major risk factors. Funding: Ammalife Charity (Registered UK Charity: 1120236) and ELLY Appeal, Barts Charity (Registered UK Charity: 212563), NIHR UK.