An analysis of the practices of caesarean section in sub-Saharan Africa: A summary of the literature

Introduction: Ensuring access to quality caesarean sections (CS) is a challenge for the next millennium and a sustainable development goal to reduce maternal and infant mortality. A CS involves risks and complications and should therefore be performed in an approved way and not used excessively. The WHO recommends that the CS rate should not exceed 10–15%. Approximately 99% of maternal deaths occur in developing countries where efforts to reduce maternal deaths are still low. This review of the literature aims to provide a summary of CS practices in sub-Saharan Africa and the consequences in terms of morbidity and mortality.


Introduction
A caesarean section (CS) is a major procedure in the management of complications during pregnancy and labour. In countries in the Global South, it accounts for the vast majority of obstetric interventions regardless of whether the indication is absolute, necessary or prudent. Ensuring quality access to CS is a key challenge for the millennium [1], and the next sustainable development goal to reduce maternal and infant mortality. As with any surgical procedure, a CS involves risks and complications and should therefore be performed in an approved way and not used excessively. Although the optimum CS at population level is diffi cult to assess, the World Health Organization (WHO) recommends that the national CS rate should not exceed 10% to 15% [2]; however, in many countries, the CS rate is rising [3]. Studies on the relationship between the CS rate and maternal and perinatal mortality and morbidity have concluded contradictory results [4][5][6][7][8]. Maternal mortality has a signifi cant impact on the surviving family, the broader community, healthcare providers and society in general. It is also frequently used as a regional or national public health indicator to assess a healthcare system's quality. Nearly 300,000 women die every year as a result of a pregnancy or a CS or vaginal delivery. Approximately 99% of these deaths occur in developing countries [9]. Systemic action is therefore needed to reduce maternal mortality. These efforts are real but remain insuffi cient, particularly in the Democratic Republic of the Congo (DRC), which is among the sub-Saharan African countries making the slowest progress in combating maternal mortality [10].
The goal of this systematic review of the literature is to provide a summary of CS practices in sub-Saharan Africa and of the consequences in terms of morbidity and mortality. It looks successively at the CS rate, its indications and the consequences of the practice in terms of maternal and perinatal mortality and morbidity.

Materials and Method
References were selected based on the following criteria: the type of study on CS, the target population and the data analysis using the following search terms on PubMed (intra-

Discussion
Caesarean frequency: The CS rate seen in this systematic review of the literature varies between 2 and 51%. Indeed, in 1985, a group of WHO experts concluded that there was 'no justifi cation for any region in the world to have a CS rate higher than 10 to 15% [76,77], It is important to note that these recommendations from the WHO are particularly valid for planned CS, the rate of which should be very low except in centres that handle high-risk pregnancies. The study by Briand [18], unfortunately shows that there are more emergency CS than elective CS performed in developing countries, which results in an increase in maternal and perinatal complications. Although a CS is an effective technique for preventing maternal and perinatal mortality when used appropriately, it is not free of risk and is associated with short-and longterm complications [6]. In our review, pregnancy-related hypertensive disorders, especially pre-eclampsia, foetal The main indications for a CS are a previous CS or scarred uterus, dystocia, foetal distress, breech presentation, antenatal haemorrhage (haemorrhagic placenta praevia, abruption of a normally positioned placenta) and pregnancy-related hypertensive disorders [10,16,21,33,38,[43][44][45][46][47]. The 'once a CS always a CS' policy is widely applied in sub-Sahara Africa, mainly from fear of uterine rupture during labour. This policy helps reduce both the uterine rupture rate and the emergency surgery responsible for the increase in maternal and perinatal mortality and morbidity. These repeat CS do not, however, result in the medical benefi ts expected. In fact, a vaginal delivery after a CS has a low risk both for the mother and for the However, lack of resources and qualifi ed staff sometimes makes this diagnosis diffi cult prior to labour. It is possible that dystocia is currently being over-diagnosed in order to warrant greater use of CS [10]. Use of partographs to assess the eutocic or dystocic progress of labour is very low [70].
Breech presentation (buttocks or feet) accounts for approximately 3.5% of all births [79]. When parameters are properly monitored, caesarean CS have not always resulted in the best outcomes in relation to a vaginal breech birth. The freer use of CS for breech presentation in sub-Saharan Africa has led to an increase in maternal mortality and morbidity and in potential risks for future pregnancies [47]. The use of external cephalic version (ECV) has attracted interest in reducing breech presentations. In developing countries, due to lack of selection criteria for vaginal or CS breech births, ECV is not widely practiced, and this leads to an increase in perinatal morbidity and mortality [79]. It is, however, worthwhile, but screening for complications of the procedure, particularly acute distress, requires foetal monitoring equipment (ultrasound, monitors, emergency delivery room) that is very rarely available due to lack of resources. Foetal distress is one of the main indications for CS in this review of the literature. Foetal distress is indicated by a change in foetal heart rhythm and this means that the foetus is not receiving suffi cient oxygen via the placenta. Lack of oxygen, or hypoxia, can cause foetal death and brain damage. As with dystocia, there were doubts over the accuracy of this diagnosis. The study by Ajah et al. on A CS rate below 15% is associated with poor maternal and neonatal outcomes, whereas a rate higher than 15% is not associated with maternal and perinatal risks.
Ye J. et al., 2016 [4] Longitudinal ecological study 2000-2012 CS rate 5-10% A CS rate higher than 10% is not associated with a decrease in maternal and perinatal mortality.
Zizza A et al. [42] Ecological study CS rate 15% This study shows an inverse relationship between the CS rate and maternal and neonatal mortality except in Europe. distress, antenatal haemorrhage (placenta praevia, abruption of a normally positioned placenta) lead to an increase in the CS rate and in the maternal and perinatal risks [11,12]. In sub-Saharan Africa, a high CS rate is associated with an increase in maternal and perinatal mortality and morbidity [13], however, the 2% rate is related to lack of access to CS for most of the women in the population group studied [15], (lack of transport infrastructure, lack of local centres, lack of fi nancial means among the population). Most CS are performed during labour and more specifi cally in the second stage (between 4 cm and full dilation), which leads to an increase in maternal and perinatal complications [16,18]. The CS rate is increasing in certain  foetal monitoring was unable to show an improvement in the infants' well-being parameters in relation to the use of a Pinard stethoscope [12]. However, this study shows an increase in the use of CS when monitoring was used, because it is diffi cult to make the distinction between foetal stress and true distress The rate of complications was 10.5% (34.5% associated with general anaesthetic and 6.7% associated with local anaesthetic).
General anaesthetic is associated with a high maternal and perinatal risk in relation to local anaesthetic.  CS is 2 to 11 times higher than after a vaginal delivery [62].
Maternal morbidity associated with CS is 5 to 10 times higher than with vaginal deliveries. As the prevalence of uterine rupture increases in the event of protracted labour and a previous CS, studying the maternal risk factors can help prevent these complications [48,49]. Performing a CS during the second stage of labour increases the risk of complications.
Anticipating the diagnosis of dyskinesia should make it possible to remove the foetus earlier and therefore reduce those risks [16]. Haemorrhagic and infectious complications are frequently seen due to lack of asepsis in the operating theatre as well as due to insuffi cient surgical training [33,59].
Improving the quality of CS is necessary to reduce maternal and perinatal complications in sub-Saharan Africa. Proper training of gynaecologists, anaesthetists and midwives is essential in order to decrease these complications.

Conclusions
In the current working conditions in sub-Saharan Africa, the risks to the mother and foetus during a CS are signifi cantly greater than during a vaginal delivery. The high maternal and perinatal morbidity and mortality rate during and after a CS is associated with a number of factors such as the indication for CS, the conditions of the intervention, the period between indication and intervention, particularly in the case of transfers, insuffi cient resuscitation equipment, as well as the quality and continuity of pre-, per-and post-operative care. The foetomaternal prognosis, therefore, depends on the quality of the transfer and their management, the quality of care, and the population's level of understanding of health problems. CS is not yet a factor in reducing foeto-maternal morbidity and mortality. The different results refl ect the ineffi ciency of the referral system for quality obstetric care. CS should be a factor in reducing foeto-maternal morbidity and mortality by improving the transfer conditions, the working conditions at referral centre level and the training of health staff. In order to help clarify the grey areas and to implement appropriate interventions, it is desirable to carry out a periodic audit to assess the quality of obstetric and neonatal care in countries where maternal mortality is high.

Author comments
This review of the literature discusses the higher maternal and perinatal mortality and morbidity in CS in relation to vaginal deliveries. This seems normal given that the CS were performed after diagnosis of often life-threatening complications.
Anticipating these complications would help reduce excessive use of CS and to assess the effectiveness of the obstetrics team.
Monitoring the foetal heart rhythm with continuous recording is more reliable than intermittent monitoring using a Pinard stethoscope, and greater awareness of the criteria for defi ning the external and internal foetal monitoring graphs makes it possible to diagnose foetal distress. In the majority of cases, training staff to correctly interpret monitoring is essential.
Although we here demonstrated CS percentage and characterized conditions related to CS in this area, we cannot answer the question 1) what percentage is the "adequate" for CS in this area, and 2) whether CS itself (surgery itself) ameliorate or deteriorate materno-neonatal mortality/morbidity. CS should be performed under an appropriate indication, at an appropriate timing and conditions. It also requires before and after care of the surgery. In this area, these are considered not well done. Therefore, it is impossible to conclude whether CS itself or non-employment of CS itself relates with the outcome.
In short, CS in developed countries and CS in developing countries (like here) is diffi cult to compare. We understand this, and still we believe that reporting these data is important as a basic data for making better health policy regarding materno-neonatal health promotion, including CS.