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

Rakesh Ghosh, Nicole Santos, Elizabeth Butrick, Anthony Wanyoro, Peter Waiswa, Eliana Kim, Dilys Walker, Rakesh Ghosh, Nicole Santos, Elizabeth Butrick, Anthony Wanyoro, Peter Waiswa, Eliana Kim, Dilys Walker

Abstract

Objective: To 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).

Design: Prospective cohort study.

Setting: 10 CS-capable facilities in Busoga Region, East-Central Uganda and Migori County, Kenya.

Participants: Individual 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 measures: Stillbirth, predischarge neonatal mortality and maternal mortality.

Results: The 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.

Conclusion: In 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 number: NCT03112018.

Keywords: epidemiology; obstetrics; quality in health care.

Conflict of interest statement

Competing interests: None declared.

© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.

Figures

Figure 1
Figure 1
Flow diagram describing the final analytical sample and exclusions. CS, caesarean section; PTBi, Preterm Birth Initiative.
Figure 2
Figure 2
Adjusted! OR and 95% CI for facility-based pregnancy related death and caesarean section stratified by birth outcome and referral status!. ! Adjusted for birth weight, annual delivery volume, type of facility, country and exposure to PTBi intervention. Note—After adjusting for multiple comparison using false discovery rate method, the interaction p values changed to 0.0003 and 0.29, respectively. PTBi, Preterm Birth Initiative.
Figure 3
Figure 3
Adjusted! OR and 95% CI for adverse neonatal outcomes and caesarean section stratified by referral status!. ! Adjusted for birth weight, annual delivery volume, type of facility, country and exposure to PTBi intervention. Note—After adjusting for multiple comparison using false discovery rate method, the interaction p values changed to 0.04 for stillbirth, to 0.003 for Apgar, and remained unchanged at 0.85 for predischarge mortality. PTBi, preterm birth initiative.

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