Trial of labour after caesarean section in Sub‐Saharan Africa: A systematic review and meta‐analysis

Abstract

The objective of this study is to determine the proportion of women undergoing trial of labour after caesarean (TOLAC) and vaginal birth after caesarean (VBAC) in Sub‐Saharan Africa (SSA), and to estimate associated adverse events.We searched PubMed, MEDLINE, CAB, EMBASE and African‐specific databases from 1966 to July 2023, including SSA studies reporting on women with previous caesarean section (CS). We extracted data on study design, planned (TOLAC versus elective repeat CS (ERCS)) and actual delivery mode, and adverse outcomes. We calculated mean TOLAC and VBAC proportions, and pooled proportion of adverse events, comparing between TOLAC and ERCS where available. We assessed bias using the methodological index for nonrandomized studies.From 62 studies with 36 611 births, the estimated proportion undergoing TOLAC and achieving VBAC, adjusted for study variability, were 79% (95% confidence interval [95% CI]: 74%, 85%) and 47% (95% CI: 42%, 51%), respectively, for all births. Mean estimated uterine rupture proportion and maternal mortality were 2.1% (95% CI: 1.1%, 3.2%) and 0.1% (95% CI: 0.02%, 0.2%) respectively. We found no differences between TOLAC and ERCS for uterine rupture (1.2% vs. 0.2%, pooled odds ratio [OR]: 1.54; 95% CI: 0.63, 3.8) or maternal mortality (0.3% vs. <0.1%, pooled OR: 0.77; 95% CI: 0.30, 2.0), respectively. However perinatal mortality was higher with TOLAC compared to ERCS (5% vs. 1%; pooled OR: 3.3; 95% CI: 1.5, 6.9).We found high proportions of women undergoing TOLAC and moderate proportions of successful VBAC across SSA, with a higher perinatal mortality associated with TOLAC. Few studies reported on adverse outcomes and used inconsistent definitions. Further research is needed to understand outcomes in this population of women in these settings.The study protocol was registered with PROSPERO (CRD42020175434).