Stillbirth, neonatal and maternal mortality among caesarean births in Kenya and Uganda: a register-based prospective cohort study

Abstract

ObjectiveTo investigate the interaction of risks for adverse maternal and perinatal outcomes (stillbirth, predischarge neonatal and maternal mortality) among caesarean section (CS) compared with vaginal deliveries (VD).DesignProspective cohort study.Setting10 CS-capable facilities in Busoga Region, East-Central Uganda and Migori County, Kenya.ParticipantsIndividual birth data were extracted from maternity registers between October 2016 and April 2019. There were a total of 77 242 livebirths and 3734 stillbirths. Overall, 24% of deliveries were by CS with a range of 9%–49% across facilities.Primary outcome measuresStillbirth, predischarge neonatal mortality and maternal mortality.ResultsThe adjusted ORs for stillbirth, predischarge neonatal mortality and maternal mortality after a CS were 1.3 (95% CI 1.1 to 1.6), 1.9 (95% CI 1.6 to 2.2) and 3.3 (95% CI 2.2 to 4.9), respectively, compared with a VD. The association between maternal mortality and CS was 3.9 (95% CI 2.8 to 5.5) when the delivery was a live birth and 1.7 (95% CI 1.0 to 3.0) when it was a stillbirth. Post hoc analyses showed that mothers who received a CS had a lower risk of stillbirth if they were documented as a referral.ConclusionIn this context, CS births were at higher risk for worse outcomes compared with VD. Better understanding of CS use and associated adverse outcomes within the mother–baby dyad is necessary to identify opportunities to improve quality of intrapartum care.Trial registration numberNCT03112018.

Incidence and Factors Associated with Immediate Adverse Neonatal Outcomes Among Emergency Obstetric Referrals in Labor at a Tertiary Hospital in Uganda: A Prospective Cohort Study

“…Higher incidences of FSB of 23.4%, was registered in Rwanda [10] and in Eastern Uganda [23] at 43.8%. Moreover, a 37.0% increase in the incidence of low Apgar was noted in Kenya [15]. Additionally, in Nepal [12] a high incidence of NICU admission of 40% was reported, while in Rwanda [10] and Eastern Uganda [23] a higher incidence of early neonatal death of 2.3%, and 37.2% respectively, were recorded.…”

“…Additionally in western Uganda [24] lower incidences of early neonatal deaths (0.6%) was also reported. Meanwhile, a study in the Netherlands [15] also found low Apgar scores (2.7%).…”

“…The ndings in India [17] was a population-based study that had a longer duration (4 years) and larger sample size (34,319 participants) hence a bigger denominator. In the Netherlands [15], the study was retrospective not in African or lowincome countries like Uganda where this study was carried out. Therefore, better and quality service provision among referrals could have improved the outcomes.…”

“…The incidence of adverse neonatal outcomes such as neonatal deaths, low APGAR score, fresh stillbirths, early neonatal infections, and admission to NICU among obstetric referrals varies between countries and settings from 10 to 45% [10,12]. For instance, the Netherlands, Malawi, and Kenya demonstrated this [8, 13,14,15], Nepal indicated a range of 18 to 42%, India 7.3-47%, Nigeria 16.4-47%, Ethiopia 16 to 37.4%, and Rwanda 10 to 37.1% [12,16,17,18,19,11,20,10]. Reported incidences in Uganda vary from region to region, 0.6 to 19.2% (Western Uganda) and 8.1 to 33.3% (North and Eastern Uganda) for low APGAR score, FSB, Early neonatal deaths and NICU admissions [21,22,23].…”

“…Obstetric factors, sociodemographic factors, and obstetric delays are the key attributes of adverse neonatal outcomes and their variation in incidences regionally and per country [18,19,11,12]. Low socioeconomic status, low levels of education, rural residency, large family status, delays in reaching & receiving care at referral site, and obstetric factors such as prolonged labor, antepartum hemorrhage (APH), obstructed labor, fetal distress, hypertensive disorders are the great in uencers adverse neonatal outcomes in low-income settings like Uganda [6, 7,14,15,13,8]. For example, a study indicated 7.7 times the risks of adverse neonatal among women with APH [9,10], and in western Uganda, attributes were made to malpresentation and previous cesarean section [24] East and Northern Uganda have the highest incidences compared to other regions, and attributes to this have been made to, lower socioeconomic status, lower education level, maternal age ≥ 35years or age ≤ 20 years, referral delays (especially third and second delays), under-resourced facilities, understa ng of critical cadres [25,26,24,23,21,27].…”