The need for improved safety during Caesarean sections has been highlighted in research findings by an Honorary Clinical Associate in UKZN’s Department of Anaesthetics.
Researcher Dr David Bishop is the first author of a study titled: Maternal and Neonatal Outcomes after Caesarean Delivery in the African Surgical Outcomes Study: a 7-day Prospective Observational Cohort Study, recently published in the prestigious scientific journal: The Lancet Global Health.
The findings highlight the need for improved safety in Caesarean sections (C-section), especially because the procedure is the most common surgery performed in Africa.
The study, involving more than 3 500 mothers, was conducted in 183 hospitals in 22 African countries. About 40% of the hospitals are in South Africa and of those, a total of 14 are in KwaZulu-Natal.
Investigations revealed that one in six women developed complications during surgery, nearly three times the ratio of women in the United States who experienced problems. Intraoperative and postoperative bleeding was the most common complication in Africa.
Commenting on the findings, Bishop said: ‘Improvement of C-section surgical outcomes could substantially improve both maternal and neonatal mortality, which would lead to key global health gains. Our findings could potentially inform interventions to improve the safety of C-sections for both mother and baby. Areas that should be targeted include early risk identification (i.e. risk of bleeding), consideration of a lower threshold for the use of drugs used to treat post-partum haemorrhage especially where availability of blood is low; improvement of access to blood and blood products with long shelf lives, and novel methods of training of non-physician anaesthetists, including online support and mobile-based applications.’
This study forms part of a larger African Surgical Outcomes Study (ASOS), a cohort project measuring the surgical outcomes of all patients who received surgery during a seven-day period in 247 hospitals across 25 countries in Africa. The intention of this international African, multicentre study was to provide a pragmatic solution to decreasing postoperative morbidity and mortality across Africa. In this particular study, C-sections were found to be the most common surgery, accounting for a third of all surgical procedures.
The study also indicated that the vast majority of surgeries recorded were emergency C-sections with mothers arriving at surgery with an already high preoperative risk due to pregnancy-related complications. The authors found that there was a need for improved access to surgery, safer procedures, more specialist care as well as safer anaesthesia for women during Caesarean delivery.
Another finding was the scarcity of specialist care available which amounted to an average of 0.7 specialists per 100 000 population. Hospitals surveyed had an average of three specialist obstetricians, three specialist surgeons and two specialist anaesthesiologists. Almost one in four women received anaesthesia from a non-specialist, and since 10% of the deaths recorded happened after anaesthesia complications, the authors highlighted the need for safer anaesthesia for women during Caesarean delivery.
‘Paradoxically, while many countries are aiming to reduce the Caesarean delivery rate, increasing the rate of Caesarean delivery remains a priority in Africa,’ said Professor Bruce Biccard who led the study. ‘In sub-Saharan Africa, the Caesarean delivery rate is static at 3.5%, despite an increasing pattern in rates globally. Improving access to surgery might allow patients to present earlier and prevent complications and deaths but it is vital that this improvement occurs in parallel with programmes aimed at improving patient safety during Caesarean delivery.’
Biccard is a former Associate Professor at UKZN’s Department of Anaesthetics and is currently based in the University of Cape Town’s Department of Anaesthetics.
Bishop, a specialist anaesthesiologist currently working as the District Clinical Specialist in the uMgungundlovu District in KwaZulu-Natal, is an honorary clinical associate at the University of KwaZulu-Natal. His main interests are obstetric anaesthesia, burns anaesthesia and autonomic dysfunction. He is a National Committee of Confidential Enquiries into Maternal Deaths (NCCEMD) provincial assessor and is currently the president of the Obstetric Anaesthesia Special Interest Society. He recently completed his doctoral thesis on pragmatic approaches to obstetric spinal hypotension in a resource limited setting.
Words: MaryAnn Francis and David Bishop