Caesarean section is the most common surgical procedure in sub-Saharan Africa. But it is much more risky for mothers and babies there than in wealthier regions. Researchers from the Malawi College of Medicine and the London School of Hygiene and Tropical Medicine looked into the reasons for this difference.

The study involved 45 anaesthetists at 23 district and two central hospitals in Malawi. They filled out questionnaires about the course and outcome of more than 8000 caesarean sections. The researchers used the data to address several questions:

• Is the risk of death greater for mothers during surgery or in the wards afterwards?
• Do outcomes differ between district and central hospitals?
• Which risk factors for maternal death could be tackled relatively easily?
• What is the impact of the level of training of surgeons and anaesthetists?
• Does the method of anaesthesia affect the risk of maternal death?

The analysis showed that most caesarean sections are emergencies. Reasons included obstructed labour (63%), foetal distress (11%), heavy bleeding (5%) and pre-eclampsia (3%). The study also found that:

• The most common serious complications seen before surgery were haemorrhagic shock (8%) and ruptured uterus (4%). 6% of women had pre-operative anaemia.
• Eighty-five women died (1.05%). More than two thirds of deaths occurred on the wards after the operation.
• Death was more common among women with a ruptured uterus and those who bled excessively.
• Spinal anaesthesia appeared to be safer than general anaesthesia.

While death rates during surgery and on the wards afterwards are high compared to those in developed countries, Malawi does better than its doctor-only neighbours, and on a smaller budget, because it has a more scattered rural service provided by non-doctors. Thus on a purely public health basis, a paramedical service is better and more cost effective than a doctor-only based service, such as those found in Nigeria, Kenya or Zimbabwe, although limited data is available from these countries.

Clinical officers, who remain the backbone of medical services in much of Africa, gave all of the anaesthetics and performed most of the operations. Anaesthetists are clinical officers who have trained in anaesthetics for 15 months after a three year foundation health course. But for 9% of these caesarean sections, the health workers who gave the anaesthetic had received on the job training but no formal tuition in anaesthetics. Improved training for anaesthetic clinical officers could help to reduce the high risks associated with caesarean section in Africa. The results of this study suggest that training should focus on:

• basic resuscitation skills, including fluid replacement, which is a relatively cheap and safe alternative to blood transfusion, especially in areas with high HIV rates
• spinal anaesthesia, which is a simple, low-cost option requiring little monitoring
• improved post-operative care.

Source(s):
‘Caesarean section in Malawi: prospective study of early maternal and perinatal mortality’, British Medical Journal 327: 587-561, by P. Fenton, C. Whitty and F. Reynolds, 2003 Full document.
'Need for caesarean sections in West Africa', Lancet 359(9310): 976, by P.M. Fenton, 2002
'Reducing perinatal and maternal mortality in the world: major challenges', British Journal of Obstetrics and Gynaecology 107(6): 831-832, by P.M. Fenton and E. Tadesse, 2000

Funded by: School of Anaesthesia, Malawi; Paul Fenton; Obstetric Anaesthetists Association

id21 Research Highlight: 11 February 2004

Further Information:
Christopher Whitty
London School of Tropical Medicine and Hygiene
Keppel Street
London
WC1E 7HT
UK

Tel: +44 (0) 20 7299 4715
Fax: +44 (0) 20 4299 4720
Contact the contributor: christopher.whitty@lshtm.ac.uk

London School of Hygiene and Tropical Medicine, UK

Paul Fenton
Meyra
47800 Agnac
France

Tel: +33 (0) 553 64 38 89
Contact the contributor: 380mj@care4free.net

College of Medicine, University of Malawi

Other related links:
'Keeping mothers alive - monitoring maternal mortality in Tanzania' >

'Is pregnancy good for your health? Evidence from Senegal' >

'Taking aim: using 'near misses' to evaluate maternal healthcare' >

'Maternal mortality in rural Gambia: levels, causes and contributing factors' >

'Dicing with death? The impact of hospital choice and other factors on maternal mortality' >

'Making practice perfect - clinical audit for better maternal health' >

See id21's collection of links relevant to maternal and child health.