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Introduction Sierra 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. Methods We 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. Results In 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. Conclusions The 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.
This is a retrospective study of reported in-facility maternal deaths in Sierra Leone in 2016, with a particular focus on deaths with caesarean section. Facility-level data on number of deliveries, caesarean sections and maternal deaths were combined with patient-level data on maternal mortality with and without caesarean section. All Sierra Leonean health facilities performing caesarean sections in 2016 were visited and numbers of caesarean sections, deliveries and maternal deaths reported in facility logbooks were recorded. The Sierra Leone MoHS provided access to the MDSR database, containing patient-level information on all maternal deaths notified through its system in 2016. Every maternal death after caesarean section was validated through on-site facility logbook review (including all available patient files, hospital logbooks, operating room logbooks and blood bank logbooks). Data were collected on paper forms, and transcribed. The 2016 population was projected from 2015 population census data,15 and the number of deliveries was derived using the World Development Indicators’ estimated crude birth rate per 1000 people for 201616 (the crude birth rate was used as there may be significant under-reporting of births through the District Health Information System, particularly for births that did not occur in health facilities). The number of caesarean sections needed was calculated by multiplying the estimated number of deliveries—live births (as above)15 16 and stillbirths (from a global analysis)17—with the expected need for caesarean section on maternal indication as a percentage of all deliveries (5.4%, from a previous study in West Africa by Dumont and colleagues in 2001).18 The 2012 caesarean section rate from Bolkan et al, collected and calculated using the same methodology, was used for comparison over time.9 19 Facilities performing caesarean sections in 2016 were included in the facility-level analysis. To minimise the risk of under-reporting among facilities with no maternal deaths in the MDSR database, we cross-validated the findings with the number of maternal deaths from logbook data and excluded facilities with one or more maternal deaths according to logbooks, which had zero maternal deaths in the MDSR database. All patients in the MDSR database who died in a facility were included in the patient-level analysis. Maternal deaths outside facilities were excluded to improve comparability, and for patients who underwent caesarean section, deaths that occurred after discharge (including after readmission) were excluded in keeping with the standard definition of in-facility perioperative death. Logbooks were reviewed for all patients noted to have undergone caesarean section prior to, or at the time of death. Inclusion and exclusion criteria are summarised in figure 1. Caesarean section was defined by the provider. Inclusion and exclusion criteria. Maternal deaths with and without caesarean section in Sierra Leone, 2016. Primary outcomes were caesarean section rate and mortality rate. The definitions used for in-facility and population-level caesarean section rates are detailed in table 1, as are those used for mortality rates of all in-facility deliveries and those with caesarean section. To align with the WHO definition of perioperative mortality,20 in-facility mortality was selected rather than 42-day mortality which is commonly used for maternal death reporting. Secondary outcomes were time from admission to death, time from operation to death, cause of death (as categorised by Say et al 2), intraoperative findings and fetal outcome. Definitions of caesarean section rates and mortality rates Facility-specific variables included facility type (peripheral health unit—primary healthcare centres including Maternal and Child Health Post, Community Health Post and Community Health Centre21—district hospital, or referral hospital), annual number of deliveries, number of maternal deaths and number of deaths associated with caesarean section. Patient-specific variables included age, gravidity, parity, number of antenatal care visits, referral history, indication for caesarean section, preoperative haemoglobin level, blood transfusion and number of units given, time from admission to start of operation, operation length, type of anaesthesia and type of surgical provider. In-facility and population rates of caesarean section were stratified by district. In-facility rates were calculated for facilities performing caesarean section, and used to calculate a median value with IQR. All rates were provided as percentages. The rate of caesarean sections in 2016 was compared with that in 2012. Characteristics of maternal deaths with and without caesarean section were compared using the Mann-Whitney U test for non-normally distributed continuous variables and Fisher’s exact test for binary outcomes. Time from admission to caesarean section, and time from caesarean section to death, were presented in Kaplan-Meier plots, with patients censored at death or at the time of discharge. Facilities were grouped based on their respective caesarean section mortality rate, and differences in patient characteristics, clinical management and outcomes were analysed using Kruskal-Wallis test for continuous variables and Fisher-Freeman-Halton test for categorical and binary outcomes. The association between caesarean section mortality and the rate and volume of caesarean section (using its common logarithm) was described using univariate linear regressions, with β and 95% CIs. Statistical analysis was done in R (V.3.5.1, The R Project for Statistical Computing). Ethical approval was granted by the Sierra Leone Ethics and Scientific Review Committee to collect facility-level data (16 May 2016) and patient-level data (10 August 2017). Informed written consent was sought from the medical superintendent of each facility ahead of data collection. Personal identifiers were transcribed and kept on a password-protected computer. We did not involve patients or the public in our work.
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