Association between prelabour caesarean section and perinatal outcomes: analysis of demographic and health surveys from 26 low-income and middle-income countries

OBJECTIVES: Caesarean section (CS) conducted before labour (prelabour CS (PLCS)), compared with vaginal birth, may pose additional maternal and perinatal risks. No multicountry analysis has examined PLCS in low-income and middle-income countries (LMICs). This study assessed rates, risk factors and associations of PLCS with perinatal outcomes in LMICs. DESIGN: Population-based cross-sectional surveys. SETTING: Demographic and Health Surveys conducted between 2015 and 2018 in 26 LMICs (13 countries in Africa, 11 in Asia and 2 in the Americas). PARTICIPANTS: Women aged 15–49 years with singleton term births. OUTCOME MEASURES: Main outcomes were early neonatal mortality, neonatal mortality, early breastfeeding (within 1 hour of birth), skin-to-skin contact and duration of hospital stay. RESULTS: 255 227 women were included in the main analysis. Average rates of primary PLCS ranged from 1.3% in Zambia to 19.5% in Maldives. Median PLCS rate was 1.8% in the poorest versus 5.8% in the richest subgroups. Higher maternal age, education, economic status and BMI, lower parity, urban residence, delivery in private hospitals, larger baby size, having health insurance, more antenatal care (ANC) visits, ANC by a doctor and ANC in private hospitals were associated with increased primary PLCS. Across the 26 countries, primary PLCS, compared with vaginal delivery, was associated with increased neonatal mortality (adjusted odds ratio, aOR 1.2, 95% CI 1.0 to 1.5), decreased early breastfeeding (aOR 0.4, 95% CI 0.3 to 0.5) and skin-to-skin contact (aOR 0.4, 95% CI 0.3 to 0.5) and longer hospital stay (aOR 6.6, 95% CI 5.9 to 7.4). No significant association was found for early neonatal mortality (aOR 1.2, 95% CI 0.9 to 1.5). CONCLUSION: Primary PLCS, compared with vaginal birth, is associated with adverse perinatal outcomes in singleton term pregnancies in LMICs. Caesarean births should be audited regularly to monitor trends, appropriateness and context-specific drivers of CS.