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.