The rate and perioperative mortality of caesarean section in Sierra Leone

Abstract

IntroductionSierra Leone has the world’s highest maternal mortality, partly due to low access to caesarean section. Limited data are available to guide improvement. In this study, we aimed to analyse the rate and mortality of caesarean sections in the country.MethodsWe conducted a retrospective study of all caesarean sections and all reported in-facility maternal deaths in Sierra Leone in 2016. All facilities performing caesarean sections were visited. Data on in-facility maternal deaths were retrieved from the Maternal Death Surveillance and Response database. Caesarean section mortality was defined as in-facility perioperative mortality.ResultsIn 2016, there were 7357 caesarean sections in Sierra Leone. This yields a population rate of 2.9% of all live births, a 35% increase from 2012, with district rates ranging from 0.4% to 5.2%. The most common indications for surgery were obstructed labour (42%), hypertensive disorders (25%) and haemorrhage (22%). Ninety-nine deaths occurred during or after caesarean section, and the in-facility perioperative caesarean section mortality rate was 1.5% (median 0.7%, IQR 0–2.2). Haemorrhage was the leading cause of death (73%), and of those who died during or after surgery, 80% had general anaesthesia, 75% received blood transfusion and 22% had a uterine rupture diagnosed.ConclusionsThe caesarean section rate has increased rapidly in Sierra Leone, but the distribution remains uneven. Caesarean section mortality is high, but there is wide variation. More access to caesarean sections for maternal and neonatal complications is needed in underserved areas, and expansion should be coupled with efforts to limit late presentation, to offer assisted vaginal delivery when indicated and to ensure optimal perioperative care.

Travel time and perinatal mortality after emergency caesarean sections: an evaluation of the 2-hour proximity indicator in Sierra Leone

“…17 More than half (54.4%) of the deliveries take place in a health facility, 18 either in one of the 1160 primary healthcare units, or 24 public or 30 private hospitals. 19 The national population caesarean section rate is 2.9%, 20 far below the suggested threshold of 10%–19%, 21 22 and reflects limited access to emergency obstetric services in the country. Delayed and substandard care results in a perinatal mortality rate after caesarean section of 190 per 1000 births, 18 much higher than the national perinatal mortality rate of 39 per 1000 pregnancies.…”

Perinatal outcomes of cesarean deliveries in Sierra Leone: A prospective multicenter observational study

“…The strength of the present study is its prospective design with home visits after 1 month, allowing us to validate data gathered during admission. The nine study hospitals cover different categories with a wide geographic distribution and account for almost half of all cesarean deliveries performed in the country . The inclusion period was purposefully done in the dry season, to be able to maximize the follow‐up rate, as many roads are impassable during the rainy season.…”

“… Annual cesarean deliveries and total deliveries by facility in 2016, with permission from Holmer et al. 2019 …”

“…Sierra Leone has one of the world's poorest perinatal health indicators, with a national cesarean delivery rate of 2.9% and an overall perinatal mortality rate of 39 per 1000 pregnancies . A prospective multicenter study assessing outcomes after cesarean deliveries performed by medical doctors and associate clinicians in Sierra Leone revealed a five times higher perinatal mortality rate (190 per 1000 births [n = 261/1376]) .…”

Prevalence of use of highly concentrated oxytocin or “pepper injection” in labor among clinicians undergoing emergency obstetric training in Sierra Leone

“…The only tertiary referral maternity hospital reported a 1% rate of uterine rupture in their general population of pregnant women in 2018 13 . This is relatively high when compared with global estimates, especially given the low rate of cesarean delivery (2.9%) in the country 14 . Given the high incidence of uterine rupture and its significant contribution to maternal mortality, further exploration of the inappropriate use of uterotonics among different cadres of clinicians and non‐clinicians is needed to better understand their contribution to uterine rupture in Sierra Leone.…”