Introduction
Currently, 21.1% of women deliver by caesarean section (CS) worldwide, and this is projected to rise to 28.5% by 2030, representing an estimated 38 million CS annually.1 While sub-Saharan Africa (SSA) has seen the slowest rise in rates, the regional average of 5% masks significant variation across the continent, ranging from 1.4% to 50.7%.1 Analysis of CS rates by subgroup indicates that the contribution of women with a prior caesarean to overall rates has increased substantially in SSA.2 As CS rates continue to rise, this subgroup of women will likely grow further due to the domino effect associated with repeat CS and continued high fertility rates across SSA.3
Intrapartum management for women with a prior caesarean is complex owing to the risk of uterine rupture balanced against the risk of repeat surgery. While uterine rupture rates are higher in women with a prior caesarean, repeat surgery also carries risks and may further complicate future pregnancies with increasing risks of abnormal placentation and surgical complications with each subsequent surgery.4,5 Practice patterns associated with the trial of labour after caesarean (TOLAC) versus elective repeat caesarean (ERCS) have thus fluctuated over time in response to emerging evidence around these competing risks. In the late 1990s, new evidence surrounding uterine rupture led to significant practice changes in the United States and many developed countries: rates of vaginal birth after caesarean (VBAC) dropped from 62% in studies completed before 1996 to 42% in studies conducted after 1996.4 However, similar data examining potential changes in practice patterns in SSA is limited.
There is inadequate evidence to guide decision-making and the ideal management for women with a prior CS in SSA. Extrapolating from clinical outcomes and studies of TOLAC vs ERCS in high-income countries is problematic due to the substantially different circumstances under which intrapartum care is delivered in the SSA. Indeed, studies examining outcomes after CS in SSA demonstrate maternal and perinatal mortality rates 40-50 times higher than those observed in high-income countries and maternal morbidity rates as high as 17%.6,7 This increased mortality and morbidity may reflect gaps in the ability to adequately monitor women and foetuses through a trial of labour or limitations in expedient surgical management should complications occur, raising concerns about the safety of TOLAC in SSA.8,9
There are no recent reviews synthesising the available evidence on trial of labour rates and associated clinical outcomes among women with a prior CS in SSA.10 We performed this systematic review to summarise evidence and address this gap in the literature. Our objectives were to determine rates of TOLAC and VBAC in SSA and estimate the rates of adverse maternal and perinatal events associated with TOLAC vs ERCS. We further aimed to assess if practice patterns related to management of women with a prior CS varied by subregion within SSA and whether there have been changes in practice patterns over time in sub-Saharan Africa.