Introduction
Currently, 21.1% of women deliver by caesarean section (CS) worldwide,
and this is projected to rise to 28.5% by 2030, representing an
estimated 38 million CS annually.1 While sub-Saharan
Africa (SSA) has seen the slowest rise in rates, the regional average of
5% masks significant variation across the continent, ranging from 1.4%
to 50.7%.1 Analysis of CS rates by subgroup indicates
that the contribution of women with a prior caesarean to overall rates
has increased substantially in SSA.2 As CS rates
continue to rise, this subgroup of women will likely grow further due to
the domino effect associated with repeat CS and continued high fertility
rates across SSA.3
Intrapartum management for women with a prior caesarean is complex owing
to the risk of uterine rupture balanced against the risk of repeat
surgery. While uterine rupture rates are higher in women with a prior
caesarean, repeat surgery also carries risks and may further complicate
future pregnancies with increasing risks of abnormal placentation and
surgical complications with each subsequent surgery.4,5 Practice patterns associated with the trial of
labour after caesarean (TOLAC) versus elective repeat caesarean (ERCS)
have thus fluctuated over time in response to emerging evidence around
these competing risks. In the late 1990s, new evidence surrounding
uterine rupture led to significant practice changes in the United States
and many developed countries: rates of vaginal birth after caesarean
(VBAC) dropped from 62% in studies completed before 1996 to 42% in
studies conducted after 1996.4 However, similar data
examining potential changes in practice patterns in SSA is limited.
There is inadequate evidence to guide decision-making and the ideal
management for women with a prior CS in SSA. Extrapolating from clinical
outcomes and studies of TOLAC vs ERCS in high-income countries is
problematic due to the substantially different circumstances under which
intrapartum care is delivered in the SSA. Indeed, studies examining
outcomes after CS in SSA demonstrate maternal and perinatal mortality
rates 40-50 times higher than those observed in high-income countries
and maternal morbidity rates as high as 17%.6,7 This
increased mortality and morbidity may reflect gaps in the ability to
adequately monitor women and foetuses through a trial of labour or
limitations in expedient surgical management should complications occur,
raising concerns about the safety of TOLAC in SSA.8,9
There are no recent reviews synthesising the available evidence on trial
of labour rates and associated clinical outcomes among women with a
prior CS in SSA.10 We performed this systematic review
to summarise evidence and address this gap in the literature. Our
objectives were to determine rates of TOLAC and VBAC in SSA and estimate
the rates of adverse maternal and perinatal events associated with TOLAC
vs ERCS. We further aimed to assess if practice patterns related to
management of women with a prior CS varied by subregion within SSA and
whether there have been changes in practice patterns over time in
sub-Saharan Africa.