Abstract
Recent data points to a high risk of morbidity and mortality around cesarean delivery (CD) in sub-Saharan Africa (SSA). Women with a prior CD carry higher risks in subsequent pregnancies, yet there is no recent synthesis on the optimal management of this population in SSA. We aimed to assess rates of trial of labor after cesarean (TOLAC) and elective repeat cesarean (ERCD) and associated outcomes among women with a prior CD in SSA. We searched PubMed, MEDLINE, CAB, EMBASE, African Index Medicus, and CINAHL databases from inception until July 2020. We included studies from SSA of women with a prior CD where TOLAC and ERCD rates were reported as well as maternal and perinatal outcomes. Studies in which outcomes were not reported by initial management strategy were excluded. We summarized TOLAC, vaginal birth after cesarean (VBAC) and ERCD rates. The primary outcome was uterine rupture and secondary outcomes were maternal and perinatal mortality. We calculated the pooled TOLAC and VBAC rates, and relative risks of adverse outcomes with 95% confidence intervals. We assessed quality with the Methodological Index for Non-Randomized Studies (MINORS). Twelve studies met inclusion criteria (Figure 1). This represents 20,790 women, 9,501 births in 9 countries with study dates from 1972 to 2017. The pooled TOLAC rate was 68%, ranging from 22% to 98%. The median VBAC rate was 33%, ranging from 2.4% to 84%. Pooled outcome rates and odds ratios are presented in Figure 2. There were no differences in outcomes between groups. The median MINORS score was 18 (range 17-19.5). No study met the MINORS ideal score of 24. TOLAC and VBAC rates vary widely in SSA, with no difference in outcomes by management strategy. However, the inadequately powered studies and inconsistent reporting limit the ability to draw conclusions. In light of increasing CD rates in SSA, there is an urgent need for larger well-designed studies to understand the role of TOLAC vs ERCD in SSA and optimal management strategies.View Large Image Figure ViewerDownload Hi-res image Download (PPT)
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