title: A prospective study of maternal, fetal and neonatal outcomes in the setting of cesarean section in low- and middle-income countries.
abstract: BACKGROUND
  Cesarean section (CS) rates are increasing globally with an unclear effect on pregnancy outcomes. The study objective was to quantify maternal and perinatal morbidity and mortality associated with CS compared with vaginal delivery (VD) both within and across sites in low- and middle-income countries.
  
  
  METHODS
  A prospective population-based study including home and facility births in 337 153 women with a VD and 47 308 women with a CS from 2010 to 2015 was performed in Guatemala, India, Kenya, Pakistan, Zambia and Democratic Republic of Congo. Women were enrolled during pregnancy; delivery and 6-week follow-up data were collected.
  
  
  RESULTS
  Across all sites, CS rates increased from 8.6% to 15.2%, but remained low in African sites. Younger, nulliparous women were more likely to have a CS, as were women with higher education and those delivering an infant weighing 1500-2499 g. Across all sites, maternal and neonatal mortality was higher, and stillbirths were lower, in pregnancies delivered by CS. Antepartum and postpartum complications as well as obstetric interventions and treatments were more common among women who underwent CS. In stratified analyses, all outcomes were worse in women with a CS compared with VD in African compared to non-African sites.
  
  
  CONCLUSIONS
  CS rates increased across all sites during the study period, but at more pronounced rates in the non-African sites. CS was associated with reduced postpartum hemorrhage and lower rates of stillbirths in the non-African sites. In the African sites, CS was associated with an increase in all adverse outcomes. Further studies are necessary to better understand the increase in adverse outcomes with CS in the African sites.
authors.affiliation: Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA.
authors.forename: Margo S
authors.initials: MS
authors.lastname: Harrison
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
authors.forename: Omrana
authors.identifier: http://orcid.org/0000-0003-2000-4001
authors.initials: O
authors.lastname: Pasha
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
authors.forename: Sarah
authors.identifier: http://orcid.org/0000-0002-6797-8631
authors.initials: S
authors.lastname: Saleem
authors.affiliation: Department of Community Health Sciences, Aga Khan University, Karachi, Pakistan.
authors.forename: Sumera
authors.initials: S
authors.lastname: Ali
authors.affiliation: University Teaching Hospital, University of Zambia, Lusaka, Zambia.
authors.forename: Elwyn
authors.initials: E
authors.lastname: Chomba
authors.affiliation: Division of Neonatology, University of Alabama, Birmingham, AL, USA.
authors.forename: Waldemar A
authors.initials: WA
authors.lastname: Carlo
authors.affiliation: Planning Unit, Institute of Nutrition of Central America and Panama (INCAP), Guatemala City, Guatemala.
authors.forename: Ana L
authors.initials: AL
authors.lastname: Garces
authors.affiliation: School of Medicine, University of Colorado, Denver, CO, USA.
authors.forename: Nancy F
authors.initials: NF
authors.lastname: Krebs
authors.affiliation: School of Medicine, University of Colorado, Denver, CO, USA.
authors.forename: K Michael
authors.initials: KM
authors.lastname: Hambidge
authors.affiliation: Jawaharlal Nehru Medical College, KLE University, Belgaum, India.
authors.forename: Shivaprasad S
authors.initials: SS
authors.lastname: Goudar
authors.affiliation: Jawaharlal Nehru Medical College, KLE University, Belgaum, India.
authors.forename: Bhala
authors.initials: B
authors.lastname: Kodkany
authors.affiliation: Jawaharlal Nehru Medical College, KLE University, Belgaum, India.
authors.forename: Sangappa
authors.initials: S
authors.lastname: Dhaded
authors.affiliation: Department of Obstetrics and Gynecology, Thomas Jefferson University, Philadelphia, PA, USA.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Derman
authors.affiliation: Lata Medical Research Foundation, Nagpur, India.
authors.forename: Archana
authors.initials: A
authors.lastname: Patel
authors.affiliation: School of Public Health, Boston University, Boston, MA, USA.
authors.forename: Patricia L
authors.initials: PL
authors.lastname: Hibberd
authors.affiliation: School of Medicine, Moi University, Eldoret, Kenya.
authors.forename: Fabian
authors.initials: F
authors.lastname: Esamai
authors.affiliation: School of Medicine, Indiana University, Indianapolis, IN, USA.
authors.forename: Edward A
authors.initials: EA
authors.lastname: Liechty
authors.affiliation: RTI International, Durham, NC, USA.
authors.forename: Janet L
authors.initials: JL
authors.lastname: Moore
authors.affiliation: RTI International, Durham, NC, USA.
authors.forename: Dennis
authors.initials: D
authors.lastname: Wallace
authors.affiliation: RTI International, Durham, NC, USA.
authors.forename: Elizabeth M
authors.identifier: http://orcid.org/0000-0001-8659-5444
authors.initials: EM
authors.lastname: Mcclure
authors.affiliation: Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
authors.forename: Menachem
authors.initials: M
authors.lastname: Miodovnik
authors.affiliation: Pregnancy and Perinatology Branch, Eunice Kennedy Shriver National Institute of Child Health and Human Development, Bethesda, MD, USA.
authors.forename: Marion
authors.initials: M
authors.lastname: Koso-Thomas
authors.affiliation: Institute for Clinical Effectiveness and Health Policy, Buenos Aires, Argentina.
authors.forename: Jose
authors.initials: J
authors.lastname: Belizan
authors.affiliation: Kinshasa School of Public Health, Kinshasa, Democratic Republic of the Congo.
authors.forename: Antoinette K
authors.initials: AK
authors.lastname: Tshefu
authors.affiliation: Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Bauserman
authors.affiliation: Department of Obstetrics and Gynecology, Columbia University, New York, NY, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Goldenberg
mesh_terms: D000328:Adult; D002585:Cesarean Section / Q000706:statistics & numerical data*; D003906:Developing Countries; D005260:Female; D006801:Humans; D007223:Infant; D007226:Infant Mortality; D007231:Infant, Newborn; D008297:Male; D008427:Maternal Health Services; D008428:Maternal Mortality; D007744:Obstetric Labor Complications / Q000401:mortality*; D011247:Pregnancy; D011256:Pregnancy Outcome; D011446:Prospective Studies; D012959:Socioeconomic Factors; D050497:Stillbirth / Q000453:epidemiology; D055815:Young Adult
keywords: Cesarean section; low- and middle-income countries; maternal morbidity; maternal mortality; neonatal morbidity; neonatal mortality