David Bishop1, Robert A Dyer2, Salome Maswime3, Reitze N Rodseth1, Dominique van Dyk2, Hyla-Louise Kluyts4, Janat T Tumukunde5, Farai D Madzimbamuto6, Abdulaziz M Elkhogia7, Andrew K N Ndonga8, Zipporah W W Ngumi9, Akinyinka O Omigbodun10, Simbo D Amanor-Boadu11, Eugene Zoumenou12, Apollo Basenero13, Dolly M Munlemvo14, Coulibaly Youssouf15, Gabriel Ndayisaba16, Akwasi Antwi-Kusi17, Veekash Gobin18, Patrice Forget19, Bernard Mbwele20, Henry Ndasi21, Sylvia R Rakotoarison22, Ahmadou L Samateh23, Ryad Mehyaoui24, Ushmaben Patel-Mujajati25, Chaibou M Sani26, Tonya M Esterhuizen27, Thandinkosi E Madiba28, Rupert M Pearse29, Bruce M Biccard30. 1. Perioperative Research Group, Department of Anaesthetics, Critical Care and Pain Management, University of KwaZulu-Natal, Pietermaritzburg, South Africa. 2. Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. 3. Department of Obstetrics and Gynaecology, University of the Witwatersrand, Johannesburg, South Africa. 4. Department of Anaesthesiology, Sefako Makgatho Health Sciences University, Pretoria, South Africa. 5. Department of Anaesthesiology, Makerere University, Kampala, Uganda. 6. Department of Anaesthesia and Critical Care Medicine, University of Zimbabwe College of Health Sciences, Avondale, Harare, Zimbabwe. 7. Anaesthesia Department, Tripoli Medical Centre, Tripoli, Libya. 8. General and Gastrosurgery, Mater Hospital, Nairobi, Kenya. 9. Department of Anaesthesia, University of Nairobi School of Medicine, Nairobi, Kenya. 10. Obstetrics and Gynaecology, College of Medicine, University of Ibadan, Ibadan, Nigeria. 11. Department of Anaesthesia, University College Hospital, Ibadan, Nigeria. 12. Faculté des Sciences de la Santé de Cotonou, Hôpital de la mère et de l'enfant, Lagune de Cotonou, Benin. 13. Ministry of Health and Social Services Namibia, Windhoek, Namibia. 14. Department of Anaesthesiology, University Hospital of Kinshasha, Kinshasha, Democratic Republic of Congo. 15. Department of Anaesthesiology, Faculté de Médicine de Bamako, Bamako, Mali. 16. Department of Surgery, Kamenge Teaching Hospital, Bujumbura, Burundi. 17. Department of Anaesthesiology and Intensive Care, School of Medical Sciences, College of Health Sciences, Kwame Nkrumah University of Science and Technology, Kumasi, Ghana. 18. Ministry of Health and Quality of Life, Jawaharlal Nehru Hospital, Rose Belle, Mauritius. 19. Anesthesiology and Perioperative Medicine, Vrije Universiteit Brussel, and Universitair Ziekenhuis Brussel, Brussels, Belgium. 20. Clinical Operations, HIV/AIDS Care and Treatment and Prevention of Mother-to-Child Transmission, Christian Social Service Commission, Mwanza, Tanzania. 21. Department of Orthopaedics and General Surgery, Baptist Hospital, Mutengene, Cameroon. 22. Androhibe, Madagascar. 23. Department of Surgery, Edward Francis Small Teaching Hospital, Banjul, The Gambia. 24. Hospital of Cardiovasculaire Pathology, Universitar Hospital, Algiers, Algeria. 25. Department of Anaesthesiology, University Teaching Hospital, Lusaka, Zambia. 26. Department of Anesthesiology, Intensive Care and Emergency, National Hospital of Niamey, Niamey, Niger. 27. Centre for Evidence Based Health Care, Stellenbosch University, Stellenbosch, South Africa. 28. Department of Surgery, University of KwaZulu-Natal, Durban, South Africa. 29. Intensive Care Medicine, Queen Mary University of London, London, UK. 30. Department of Anaesthesia and Perioperative Medicine, Groote Schuur Hospital, Faculty of Health Sciences, University of Cape Town, Cape Town, South Africa. Electronic address: bruce.biccard@uct.ac.za.
Abstract
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.
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.
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