Strengths and Limitations
Most studies included in this review were retrospective, and many lacked an adequate control or comparison group. In several studies, outcomes were compared by actual rather than the intended mode of delivery, making it hard to ascertain differences that can inform future clinical decision-making. Many studies also failed to report on adverse outcomes, and there was substantial heterogeneity in the inclusion and exclusion criteria and the definitions used for reporting. Additionally, most studies were performed in tertiary or university hospitals; thus, our findings in this context may not be generalisable to district or general hospitals where most facility-based deliveries in SSA occur. Regional generalizability may also be limited as most studies were conducted in West Africa and relatively few in Southern Africa.
More consistent reporting is needed across studies to gain a more nuanced and reliable understanding of outcomes in this population of women. In prior work, we have summarised that based on existing patterns of care-seeking behaviour throughout sub-Saharan Africa, comparison with the two groups TOLAC vs ERCS may be incomplete and rather, three groups of analysis are preferable 1) TOLAC – i.e. women who present in labour and are allowed to continue labouring in the hospital, or women who are induced or augmented 2) – Emergency RCD - i.e. women presenting in labour and whose initial plan on arrival to the hospital is for CD and 3) Elective RCD – women whose initial plan is for a scheduled non-laboured CD.25 We recommend considering the use of this reporting in future studies aiming to understand delivery outcomes among women in a prior cesarean delivery. We also recommend at a minimum that reported adverse outcomes include maternal and perinatal (both stillbirth and neonatal) mortality and uterine rupture rates, including other maternal and perinatal adverse events such as rates of hysterectomy, ICU admission, and blood transfusion wherever possible.