Maternal and neonatal outcomes associated with cesarean section in low- and middle-income countries: Systematic review and meta-analysis — The Association Specialists
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Maternal and neonatal outcomes associated with cesarean section in low- and middle-income countries: Systematic review and meta-analysis (23944)

Tomas Y Ferede 1 2 , Jaya A R Dantas 3 , Emmanuel O Adewuyi 3 , Getaneh B Mulu 3 4 , Bereket Kefale 3 5 , Simonetta Cavilli 3 , Gizachew A Tessema 3 6
  1. Curtin University, Bentley, WESTERN AUSTRALIA, Australia
  2. School of Nursing, Hawassa University, Hawassa, Ethiopia
  3. School of population health, Curtin University, Perth, Western Australia, Australia
  4. School of Nursing, Asrat Woldeyes Health Sciences Campus, Debrebrhan University, Debrebrhan, Ethiopia
  5. School of Public Health, college of medicine and health sciences, Wollo University, Dessie, Ethiopia
  6. School of Population Health, Adelaide University, Adelaide, South Australia, Australia

Background: When medically indicated, Caesarean section (CS) can save the lives of women and newborns. Concerns are often raised on the safety, benefit, risk and equity of access to the service and outcomes associated with it in low and middle-income countries (LMICs). This study synthesises evidence on CS outcomes in LMICs.  

Methods: Following PRISMA guidelines, we searched MEDLINE, PubMed, Web of Science, Scopus, Embase, CINAHL, and Emcare, as well as grey literature, to identify studies reporting maternal and neonatal outcomes associated with CS from 2010 to 2025.  Two reviewers independently screened studies and assessed quality using JBI. Evidence was synthesised using random effect model with restricted maximum likelihood (REML).

Results:  A total of 104 studies were included. Compared with vaginal delivery(VD), CS was associated with increased odds of maternal death (AOR = 2.89, 95% CI 2.40-3.47; I2 = 0.0%), maternal near miss (AOR = 2.42,95% CI 1.11-5.27; I2 = 96.4%), puerperal sepsis (AOR = 2.91,95% CI 2.12–4.01; I² = 0.0%), neonatal mortality (AOR = 1.47, 95% CI 0.98–2.22; I² = 84.8%), neonatal near miss (AOR = 2.08, 95% CI 1.45–2.98; I² = 78.3%) and perinatal asphyxia (AOR = 2.36,95% CI 1.40-3.99; I2 = 56.8%). Maternal outcomes show stronger association in low or lower middle income countries (LLMICs) than in upper middle income countries(UMICs), with AOR = 3.12, 95% CI 2.49-3.90); I2 = 0.0%  versus AOR= 2.44 95% CI 1.75-3.39; I2 = 0.0% in maternal mortality and  AOR = 3.69, 95% CI 1.98-6.86); I2= 0.0% versus  AOR = 2.03, 95% CI 0.53-7.82; I2 = 98.9% in maternal near miss.

Conclusion: We found that CS is associated with adverse maternal and neonatal outcomes in LMICs, especially in limited-resource settings. Improving service quality, ensuring proper usage, increasing timely access to safe CS, and standardising reporting are essential to improve outcomes.