Background: Intrapartum decision-making for women with a previous caesarean section (CS) is complex due to competing risks of trial of labour after cesarean (TOLAC) and elective repeat CS (ERCS). Objective: Determine rates of TOLAC and vaginal birth after cesarean (VBAC) in sub-Saharan Africa (SSA) and estimate rates of adverse events associated with TOLAC versus ERCS. Search Strategy: We searched PubMed, MEDLINE, CAB, EMBASE, and African-specific databases. Selection Criteria: We included studies with at least one previous CS conducted in SSA. Data Collection and Analysis: We extracted data on study design, planned and actual delivery mode, and maternal and perinatal outcomes. We calculated median TOLAC and VBAC rates pooled mean uterine rupture rate and compared uterine rupture rates and mortality between TOLAC and ERCS. Main Results: From 51 included studies, the median TOLAC and VBAC rates, weighted for sample size, were 75% (IQR: 40-100%) and 34% (IQR: 24-44%) , respectively; and the weighted mean uterine rupture rate was 1.3% (SD: 1.6%). The uterine rupture rate [1.2% vs 0.2%, OR 1.54 (95% CI 0.63-3.75)] and maternal mortality [0.3% vs <0.1%, OR 0.77 (95% CI 0.30-1.98)] did not differ significantly between TOLAC and ERCS groups, respectively, however perinatal mortality was higher for the TOLAC group (5% vs 1%, OR 3.3 ; 95% CI 1.5-6.9) Conclusions: We found high rates of TOLAC and moderate rates of VBAC across SSA, with a perinatal but no maternal benefit to ERCS compared to TOLAC. Further research is needed to understand delivery outcomes in this population of women.

Objective: Assessment of the cost-effectiveness of strategies to scale up cesarean sections (CS) Design: Cost-effectiveness analysis to evaluate three different strategies to scale up CS Setting: Rural and urban areas of India with varying rates of CS and access to comprehensive emergency obstetric care (CEmOC) Population: Women of reproductive age in India Methods: Three strategies with different access to CEmOC and CS rates were evaluated: (A) India’s national average (50.2% access, 17.2% CS rate), (B) rural areas (47.2% access, 12.8% CS rate) and (C) urban areas (55.7% access, 28.2% CS rate). We performed a first-order Monte Carlo simulation using a 1-year cycle time and 35-year time horizon. All inputs were derived from literature. A societal perspective was utilized with a willingness-to-pay threshold of $1,940. Main outcome measures: Costs and quality-adjusted life years were used to calculate the incremental cost-effectiveness ratio (ICER). Maternal and neonatal outcomes were calculated. Results: Strategy C with the highest access to CEmOC despite the highest CS rate was cost-effective, with an ICER of 354.90. Two-way sensitivity analysis demonstrated this was driven by increased access to CEmOC. The highest CS rate strategy had the highest number of previa, accreta and ICU admissions. The strategy with the lowest access to CEmOC had the highest number of fistulae, uterine rupture, and stillbirths. Conclusions: Morbidity and mortality result from lack of access to CEmOC and overuse of CS. While interventions are needed to address both, increasing access to surgical obstetric care drives cost-effectiveness and is paramount to optimize outcomes.