In this paper, the intrinsic risk of caesarean sections was assessed. Caesarean sections were associated with an intrinsic risk for short-term severe maternal outcomes. Overall, this risk was higher in African countries than in Asia or Latin America. These findings corroborate the previous WHO Global Survey continental-level analyses [5
] and also provide further evidence for cautioning physicians and patients about issues related with caesarean sections with no medical indications.
Over the years, it has been noted in the medical literature that the interaction between the maternal underlying condition and the caesarean section operation complicates the assessment of caesarean section intrinsic risk. In order to address this issue, we tried to account for the contribution of the medical conditions leading to the operation, other risk factors, confounders and effect modifiers through multilevel statistical modeling. The results of this statistical adjustment (presented in Table ) show a substantial positive association between caesarean section and severe maternal outcomes. Similar methods were used in the previous continental analysis for Asia and it is reassuring to find a consistent trend in the two other continents. Furthering this approach, we conducted a subgroup analysis including only women with no identifiable medical risk factors: the caesarean section operation was found to increase the risk of severe maternal outcomes. Stratifying the assessment at continent and country level, similar findings were found. Operative vaginal delivery was also found to be associated with an increased risk of severe maternal outcomes suggesting that these interventions should be performed very carefully by trained providers and only when necessary.
Severe maternal outcomes are relatively rare conditions during pregnancy and childbirth. This factor may contribute to the misperception of safety related to caesarean section and lead to the overuse of the procedure. The relatively low frequency of severe outcomes also makes their appropriate assessment more complex, requiring large databases. The present analysis and findings were possible due to key features of the WHO Global Survey on Maternal and Perinatal Health project. In this project, standard methods were used across 373 hospitals around the world, generating a consistent and large database, containing a considerable number of severe maternal outcomes, including maternal deaths, intensive care unit admission, blood transfusion and hysterectomy. Another unique feature of the database was the concurrent data collection in all participating health facilities in each region thus ensuring that clinical practice in the various settings was captured during the same period. Quality features of the study also ensured that nearly all deliveries in each health facility during the study period were recorded.
Nevertheless, we should acknowledge some weaknesses of this study. The first one is the study design. This is a cross-sectional study, which per se makes this evaluation unable to establish causal relationships between caesarean sections and the maternal outcomes. However, considering the existing constraints in terms of using other designs, we consider this a fair approach to the question. Another point is that our findings may not be country or continent representative; our sample was based on a random selection of countries, regions within countries and health facilities. Doing so, we simply aimed at avoiding other selection biases, and tried to be inclusive as much as possible, considering the available resources we had. Another issue that should be considered is the disproportionately higher contribution of Chinese health facilities to the group of women undergoing caesarean sections without medical indications. The "country" variable was included in the statistical model used to adjust the findings, reducing both the clustering effect and the role of an individual country's contribution to the results. On the other hand, in the assessment of caesarean sections with indications, the Chinese facilities' contribution was not especially prominent and the findings were similar.
The low frequency of events makes the absolute risk associated with caesarean sections low, but even this low risk is substantially higher when compared to spontaneous vaginal deliveries. From the population perspective and considering the frequency with which the procedure is practiced, these findings may be relevant for avoiding the occurrence of severe maternal outcomes, especially in those settings where avoidable caesarean sections are more prevalent.
In this context, one could speculate about the relationship of these findings with the underlying health system and the implication of these results to developed countries. The higher intrinsic risk of caesarean sections observed in Africa compared to Asia and Latin America and the lower intrinsic risk in Latin America compared to Asia could suggest some ecological relationship between the strength of health system, urbanization, facility-based care and development status with the safety of surgical procedures including caesarean section. Data from Japan, the only developed country that took part in the study, could clarify that, but the low number of severe maternal outcomes actually prevented a conclusive assessment by country. Nevertheless, the above mentioned ecological relationship could suggest that in developed settings the intrinsic risk of caesarean sections would be lower compared to less developed settings.