Discussion
We used data from secondary and tertiary hospital facilities in Malawi to conduct a comprehensive review of all postnatal maternal deaths occurring nationally between 2020 and 2022. Women who gave birth by CS were over five times more likely to die than women who delivered vaginally, and over half of all postnatal maternal deaths followed a CS. Leading causes of death for women who delivered by CS were postpartum haemorrhage, eclampsia and infection. We found several modifiable health system factors to be more frequently associated with CS including ‘“prolonged abnormal observations without action’, ‘delay in starting treatment’ and ‘lack of blood transfusion’.
High burden of deaths following CS
We found that over half of all postnatal maternal deaths followed a CS. This was unexpected given the relatively low national CS rate; estimated at less than 10% of live births.8 11 This indicates that women undergoing CS are over-represented among maternal deaths. In comparison with global data, Malawi has a higher proportion of CS-related maternal deaths. Worldwide, 32.8% of postnatal maternal deaths follow a CS; in sub-Saharan Africa this rises to 38%.
The strong association found between CS and maternal death may be attributable to complications caused by the procedure itself. However, CS can also be used as a potentially life-saving intervention for a woman in extremis where death occurs despite the use of the procedure rather than because of it. Most CS in this context are carried out as emergency/unplanned procedures11 12 rather than electively, and therefore, carry a higher risk of morbidity and mortality.8 A limitation of our analysis is the lack of sufficient data to determine the role of CS in causing the death of the woman, as we did not have information regarding the indication for the procedure. This difficulty has been highlighted by other studies. Sobhy et al were unable to adjust for indications for CS in their global meta-analysis of maternal mortality and complications associated with CS in LMICs, nor was this review able to identify whether adverse outcomes observed were due to the procedure itself or from a pre-existing factor. While previous studies have identified obstructed/delayed labours as the most common indication for CS in Malawi12 (and in global LMIC settings8), further study comparing indications for CS among women who died following the procedure compared with those who survive is required. Furthermore, our data did not include information about whether a CS was carried out as an emergency or a planned procedure. However, it should be noted that CS in the Malawian context is almost exclusively carried out as an emergency/unplanned procedure, and that therefore this can be assumed of the CS carried out among the cohort we report on. From the most recent Demographic and Health Survey (2015–2016), it is known that of the 6% of live births which were delivered by CS in Malawi, only 1% were conducted before the onset of labour pains,11
Causes of death following CS
We found postpartum haemorrhage, pregnancy-specific infection, uterine rupture and antepartum haemorrhage to be important causes of death among women who died following CS. Though we could identify no previous analysis detailing causes of death following CS in Malawi, our findings are in keeping with global data. Sobhy et al found that one-third of deaths following CS were attributed to postpartum haemorrhage (32%), one-fifth to sepsis (22%) and one-fifth to pre-eclampsia (19%).8 Stratification of cause of death following CS by region or country income level was not included in their analysis for detailed comparison to our findings.
Avoidable factors
An important feature of our study is the analysis of avoidable health system factors contributing to maternal deaths following CS, allowing deeper insight into the events leading to the woman’s death. Local MDSR committees identified key remediable factors which are important opportunities to prevent avoidable maternal deaths. We found that the factors most frequently associated with death following CS were ‘delay in starting treatment’, ‘inadequate monitoring’, ‘prolonged abnormal observations without action’, ‘lack of essential equipment’ and ‘lack of blood transfusion’. Several factors were significantly more frequently linked to CS births than to vaginal births, including ‘delay in starting treatment’, ‘prolonged abnormal observations without action’, ‘lack of blood transfusion’ and ‘an absence of trained staff on duty’.
Our findings suggest that maternal deaths in this setting result from a complex interaction of human factors and health system constraints including the limited availability of critical resources. Although Malawi has successfully increased the uptake of facility-based birth in recent years, with over 90% of women now delivering at health facilities,13 the provision of quality care remains challenging, broadly due unavailability of medications and equipment, substandard infrastructure (eg, electricity, water and transport),14 and an unmet need of around 36% in the maternity workforce.15 Regarding the context in which CS procedures are carried out, it should be noted that they are generally performed at Central and District hospital level, with some larger primary care facilities also providing this service. Rates of CS are higher in urban centres and among women of the highest educational attainment and wealth quintiles11 Outside of the four central hospitals in Malawi, CS are generally carried out by clinical officers, rather than medical doctors. Clinical officers could be better supported by having better access to senior surgical support and enhanced ongoing training and mentorship to develop or improve their surgical skills.
Strengths and limitations
Our study is strengthened by robust digital data collection from across all government secondary and tertiary level facilities in Malawi. As most women in Malawi deliver at governmental healthcare facilities, and because our data collection was designed to capture the small numbers of death which occurred outside hospital/clinic facilities (around 7%) or at private facilities (13% of births13), our sample can be considered representative of the Malawian context. Further strengths include specialist verification of cause of death using an internationally endorsed classification system, novel analysis of deaths following CS in the context of high maternal mortality ratios and the inclusion of an analysis of health system factors linked to maternal deaths.
Limitations of our study include the lack of a surviving group of women with which to compare those women who died following CS. We were only able to include fully audited maternal deaths in our analysis, with the possibility that facilities may have introduced bias in selecting which deaths to audit. Further to this, we were only able to capture deaths which occurred following discharge from hospital if the woman returned to one of the facilities included in the study. Indeed, our estimate of mortality following CS is significantly lower than Sobhy et al calculated for sub-Saharan Africa in a meta-analysis of mortality rates following CS (10.9 per 1000 compared with our 3.1 per 1000), though it is in keeping with mortality rates for several individual WHO African Region countries.8
Perspectives for further research
Our analysis indicates that it is necessary to improve the safe and appropriate use of CS in low-resource settings. Interventions to improve maternal health are often developed with vaginal birth in mind, neglecting to benefit those women who give birth surgically. On the other hand, interventions to improve surgical safety are often not relevant or appropriate to obstetric cases. It is, therefore, necessary to develop and trial interventions specific to improving the safety of CS birth in low-resource settings.
From our findings, interventions which may improve outcomes for women undergoing CS could include those aimed at improving general surgical care for obstetric patients, such as the development and implementation of surgical safety checklists specific to CS. They might also include interventions to improve perioperative monitoring of obstetric patients, such as task-shifting the monitoring of vital signs to auxiliary staff, implementation of maternity early warning score systems and standardised guidelines for the care of those recovering following CS. Interventions could also include simulation training, carried out in the theatre setting, to improve skills in managing obstetric emergencies.
Interventions could also be specific to the leading causes of maternal death following CS. For example, postpartum haemorrhage is the leading cause of death among post-CS patients, both in our cohort and globally. A bundled approach to the early detection and management of PPH was recently trialled across several low-resource settings16 but focused only on strategies to detect and manage PPH at vaginal birth and did not include women undergoing CS. There remains a need for evidence-based interventions to prevent, detect and managing PPH in CS patients, suitable for use in low-resource settings.
Women who delivered by CS were twice as likely to die from pregnancy-specific infections than other causes of death. Risk factors for infection following CS in low-resource settings include poor infection prevention practices and surgical sterility in the operating theatre,17 as well as events before and after surgery.17–21 As such, further research to determine feasible and effective interventions to improve infection prevention around the time of CS specific to such settings is required. For example, vaginal preparation with antiseptic immediately prior to skin incision to prevent endometritis is well evidenced by studies largely conducted in high-income countries.22 However, implementation research to improve the uptake of this intervention in high-need settings would be beneficial.
There is also a need to improve the detection and management of severe infection and sepsis.23 For example, through the use of evidence-based maternal sepsis bundles.23 24 Furthermore, there exists a paucity of published literature on the microbiology of maternal infection in African low-resource settings to inform international guideline development and clinical management.25 Further studies to determine responsible pathogens associated with post-CS infection are, therefore, necessary.