Caesarean section in Malawi: prospective study of early maternal and perinatal mortality.

OBJECTIVE: To examine potentially modifiable factors that may influence the high maternal and perinatal mortality associated with caesarean section in Malawi. DESIGN: A prospective observational study of 8070 caesarean sections performed between January 1998 and June 2000 and associated complications. SETTING: 23 district and two central hospitals in Malawi. PARTICIPANTS: 45 anaesthetists from hospitals that carried out caesarean sections. MAIN OUTCOME MEASURES: Associations between maternal or perinatal deaths in the first 72 hours and various quantifiable risk factors. RESULTS: Questionnaires were returned for 5236 caesarean sections in district hospitals and 2834 in central hospitals; 7622 (94%) were emergencies, 5110 (63%) were because of obstructed labour. Preoperative haemorrhagic shock was present in 610 women (7.6%), anaemia in 503 (6.2%), and ruptured uterus in 333 (4.1%). Eighty five women died (1.05%), 68 of whom died postoperatively on the wards. Higher maternal mortality was associated with ruptured uterus (adjusted odds ratio 2.3, 95% confidence interval 1.3 to 4.0), little anaesthetic training (2.9, 1.6 to 5.1), general as opposed to spinal anaesthesia (6.6, 2.3 to 18.7), and blood loss requiring transfusion of >or= 2 units (21.0, 11.7 to 37.7). Perinatal mortality up to 72 hours was 11.2% overall and was significantly associated with ruptured uterus and general rather than spinal anaesthesia. CONCLUSION: In sub-Saharan Africa high maternal and perinatal mortality at caesarean section is associated with major preoperative complications that are unusual in developed countries. Improved training in anaesthetics, wider use of spinal anaesthesia, and improved surveillance and resuscitation in postoperative wards might reduce mortality.