A systematic search of primary studies in peer-reviewed journals was done on MEDLINE, ScienceDirect, JSTOR Health & General Sciences Collection, CINAHL with Full Text, Health Source: Nursing/Academic Edition, MEDLINE with Full Text, PubMed, Google Scholar, Cochrane Library, African Index Medicus (AIM), Bioline International, BioMed and EBSCOhost. The search was carried out using the following keywords with Boolean terms: Cesarean birth OR Cesarean section OR C-section AND factors OR determinant OR indications AND maternal mortality, OR morbidity AND maternal referral AND health system AND SSA. Articles that could not be accessed through the electronic search were sought through the University library. Articles retrieved from the searches were screened by the author, and references were managed using Endnote version 9. The review included research articles from January 2005 to October 2020, and the search was conducted in December 2020. Articles were initially screened using titles followed by further screening using abstracts of selected articles for eligibility (Risma). Articles that did not meet the eligibility criteria at the title and abstract screening were excluded and only those that fulfilled the inclusion criteria were considered for full article review. Studies were selected based on the following criteria:

Data extraction from the included studies was carried out by the author under his supervisor’s guidance. Data extraction was done using content analysis. Articles were screened to identify the outcomes of interests and these were entered into a data extraction table. The data extraction form was generated from Microsoft Word and drawn up based on the study variables and types of data to be collected. The following study characteristics were extracted: publication characteristics (authorship list, date of publication, journal of publication and country or language of publication), study design information and outcomes assessed.

Narrative synthesis was used to synthesise the data, as most of the outcomes were qualitative in nature such as identifying risk factors, barriers and facilitators in health systems and facilities. Narrative synthesis enabled the researcher to describe and explain issues, which were discussed in the screened articles.

The data were obtained after searching on PubMed and Google Scholar in English using the keywords. A flow diagram documenting the process of study selection is in Figure 1. A total of 625 titles were identified through the literature search, other sources and the removal of duplicates. Evaluation of these citations by the author excluded a total of 324 articles because of not meeting the inclusion criteria, leading to 301 articles for review in full text. Among these articles, a total of 245 were excluded by the reviewer (reasons provided in Figure 1), leaving a total of 56 publications for final inclusion. PRISMA provides an overview of the primary features of these.

Ethical clearance to conduct this study was obtained from the University of KwaZulu-Natal Biomedical Research Ethics Committee (No. BREC/00002286/2021).

Figure 2 indicates the distribution of the 56 studies with respect to study sites where the studies were conducted.

Thirty of the studies were quantitative; 10 were qualitative and 16 used mixed methods. In terms of outcomes, 5 reported on the use of clinical protocols; 7 on the training of doctors, anaesthetist and nurses; 6 on the availability of anaesthetists and 4 on nurses accredited in maternity services, credentialing of qualified staff; 4 on the occurrence of review or supervision within the hospital and 12 on support or infrastructure. In addition, 5 identified and described the risk factors associated with the pregnancy, 6 described surgical interventions and 7 described perioperative complications associated with maternal mortality and stillbirth. Further details can be seen in Table 1.

The main risk factors that influenced maternal and perinatal mortality and morbidity after CB included poor referral and counter-referral systems, inadequate healthcare facilities, poor quality of CBs or lack of skilled staff, inequalities of access to maternity care and emergency obstetric care (EmOC) and affordable CB intervention.^{1,3,9,11,15,18,55}

An international, prospective, observational cohort study conducted in Africa on CB found that in many countries common complications that led to maternal deaths were intraoperative and postoperative bleeding, reported in 136 (3.8%) of 3612 mothers in the study; 14 (2%) of 626 patients had postoperative complications that were associated with in-hospital deaths.^8,55 However, the major obstetrical risk factors related to CB were infectious complications, operative and postoperative bleeding and stillbirth,^1,3,9,11 as well as complications associated with both general and high spinal anaesthetists (a composition of failed intubation, aspiration, cardiac arrest and hypoxia).⁸ A retrospective study of hospital records conducted in four hospitals between 2013 and 2016 in Goma, Northeast of the Democratic Republic of Congo, reported 4534 deliveries including 736 (16.2%) by CB. This study showed that fistulae were the most common outcomes because of prolonged labour. Another study conducted in Ouagadougou, Burkina Faso, in 2018 revealed that the delay in referring emergency obstetric cases contributed to 47.06% of maternal mortality.⁹ Recommendations from these studies highlighted that promoting access to CB practice and providing a quality surgical operation for all CD indications (elective or emergency cases) as well as limiting CB overuse could avert and/or reduce much of the maternal death associated with CB.

In many SSA countries, the healthcare systems are characterised by insufficient healthcare facilities, finances and inadequate resources.⁵ Access to maternal health services remains a challenge in SSA, even though some countries have adopted a user-free maternal healthcare policy.^42,55,56 A study conducted in Nigeria and Ghana revealed that inequality in access to CB intervention is still present despite the user-free maternal healthcare policy¹⁵ and that these inequalities exist among women of different sociodemographics.¹⁵ A similar study conducted in Ghana showed that the wealth status of pregnant women influenced the rise of the CD rate to 27.5% when compared to the percentage of poor women of whom only 5% had CB.¹⁵ However, living in a rural area and a low level of education increased the challenge of accessing a CB because of inadequate health infrastructures and a shortage of staff.¹⁵ Such studies highlight the fact that free access to maternal services cannot resolve the inequality regarding access to CB intervention. It is therefore important to improve the quality of the service, especially maternal healthcare services with access to skilled providers and skilled attendants, and sustain access to health services that reduce the maternal mortality associated with CB intervention.¹⁵

A study conducted in South Africa discussed characteristics of facility-based CB rates and safety in the public sector and emphasised the inequalities between the provinces. These included¹: (1) the necessity of access to a safe CB intervention throughout the entire country and (2) the process to avert the rising rates of CB as this does not confer a benefit to maternal health.¹⁴ In addition, this study highlighted the need to improve the health system in the public sector, specifically the quality of the service delivery (skilled doctors, nurses and anaesthetists that can ensure a safe CB and manage complications related to CB) and create an environment for a safe CB in terms of equipment, infrastructure and quality care to be able to manage the complications related to CB. In ddition, the report highlighted that a strategy is needed to: (1) ensure patients are adequately evaluated before booking for CB, (2) ensure a reduction in primary CB, (3) ensure protocols that will guide the provision of vaginal births after CB and (4) encourage vaginal births in selected cases, the implementation of which may reduce the increasing rate of CB and complications related to CB.¹⁸

Studies conducted in Cameroon and Nigeria reported a facility-based CB rate of 29.4% and 29.6%, respectively, which is much higher than the 10% – 15% WHO recommended rate and indicates that there is overuse of CB in the studied populations^6,18 and higher than the average CB rate (20%) in other developing countries.³⁴ Furthermore, a high proportion of the cost of CB is related to real healthcare costs, which can bring a significant burden on the health system.^44,54

Table 3 shows the CB frequency in SSA where the CB frequency varies from 0.26% to 29.7%.^6,18 The highest facility-based CB rate in this scoping review was 29.7% at Gondar University Hospital, Ethiopia and the lowest was a rate of 0.28% in Burkina Faso.^9,48 The high rate of 29.7% did not confer any benefit to reducing maternal and perinatal mortality and was significantly higher than the recommendation from the WHO, which recommends the CB rates of the country should not be greater than 10% – 15%.²⁷ However, a rate of 0.28% is also of concern and contributes to significant maternal morbidity (in the form of fistulae) and neonatal morbidity and mortality.

In SSA, the low CB rate has contributed to the rise of foetomaternal mortality and morbidity.²⁷ A facility-based study conducted in Nigeria in 2020 demonstrated a CB rate of 6.1%, which the authors concluded was because of the inequality of access to and use of maternal health intervention for the majority of women living in the rural area, which occurred despite the provision of free access to the maternal healthcare in the study setting.²⁷ Factors that contributed to the low CB rate were inadequate health facilities, poor referral, counter-referral systems and substandard equipment resulting in adverse outcomes despite the adoption of a user-free maternal health services policy in Nigeria.²⁷ Challenges of managing emergencies and referral cases for CB are dominant issues in several studies and highlight the health systems challenges in CB management.^1,3,28

An analysis of maternal deaths in the context of CS in South Africa discovered that the risk of a woman dying after CS was nearly three times that of maternal mortality following vaginal delivery (VD).⁵ The study reported that haemorrhage was the primary cause of death (5.5 deaths per 10 000 CS administered); embolism was 4.5 times more frequent after CB than VD and hypovolemic shock was 4.8 times more likely and that the number of deaths per 10 000 CB cases ranged from 10.1 to 31.9.⁵ When the CC rate in a facility was compared to the case fatality rate, a negative link was discovered, indicating that in places with a lower CB rate, the case fatality rate was higher.

According to the 2015/16 District Health Barometer, the CB rates in South Africa’s public sector facilities climbed from 15.1% in 2006 to 24.1% in 2015. According to Solanki et al.,¹⁴ Gauteng and the North-Western Cape had the biggest increases. The availability of regional, provincial tertiary and national central hospitals and the unequal access to CB intervention may be the reasons for the notable variation in CB rates among provinces. Additionally, the high concentration of community health centres (CHCs) in predominantly rural provinces may have contributed to their lower proportion.

Even though CB is an effective procedure to avert maternal and perinatal mortality when used appropriately, it is not without risk that includes both immediate and long-term complications.⁵⁰ In SSA countries, when emergency CBs are performed, there is often a high risk of complications for both the mother and the newborn. Early access to maternity services, rapid diagnosis, deciding to refer a patient after failure to induce labour with misoprostol and the early decision to refer the pregnant woman to another hospital that can safely perform a CB have been shown to decrease those risks.³⁰ However, it is important to assess the pregnancy in terms of detecting potential factors (by attending antenatal care [ANC] and early ultrasound) that can help to avert complications related to CB. In this study, some causes of those risks were analysed including the poor maternal and newborn outcome, which was the result of lack of quality antenatal care and prenatal care, insufficient numbers of skilled health staff in the maternity unit, inadequate placement of healthcare facilities and difficulties to access to referral facilities.^10,31,58 This study highlighted the need to prepare strategies that will empower the health systems to reduce maternal and perinatal mortality because of CB practice in SSA. This is particularly important for rural and overloaded DHs where there is a significant shortage of qualified staff and resources to provide a safe CB.

Reforms in the health systems and specific coaching of the staff in the maternity services (medical officers, gynaecologists, anaesthetists and midwives) are essential to decrease these complications and uncertain outcomes for pregnant women and babies after undergoing CB. However, to achieve this, health systems should provide good-quality or comprehensive EmOC that should always be available and accessible, that every woman should give birth within a maternity unit staffed by a professional, skilled attendant and that these services should be included in health systems, as well as the provision of safe obstetric anaesthesia.⁸ Poor outcomes from CB in SSA are often caused by factors related to the health systems, including inadequate training of mid-level providers, such as clinical officers and assistant medical officers, poor use of national treatment protocols, staff who are not authorised to perform CB, poor patient records and a lack of regular review of the indications for CBs that were performed.¹ The common health system factors that led to poor outcomes were the inadequate provision of resources that can save women in an obstetric emergency, absence or poorly skilled birth attendants, inappropriate distribution of health facilities and poor referral and counter-referral systems that limit access to EmOC.^38,59 This lack of access to safe CBs could be the predominant reason why some SSA counties reported a facility-based CB rate of less than 5% rather than the 10% – 15% recommended by the WHO in public and private healthcare facilities.³⁹

Health system factors that influenced the CB outcomes negatively were mainly identified in rural areas. However, some countries have shown the political will to improve their health system, for example, in Maputo, Mozambique training of health providers on the referral of a patient to another health facility or district hospital, and training of supervisors on supportive supervision was provided.¹² Another study conducted in Douala, Cameroon, identified the accreditation of skilled obstetricians and the availability of a single anaesthetist for all surgical emergencies.⁶ Furthermore, a study conducted in Lagos, Nigeria, reported that 57% of pregnant women were attended by a skilled health professional.⁶ These factors show the potential for improvement of the health systems and the impact that this could have on improving CB outcomes within and among SSA countries.

Table 4 shows the indications for CB in SSA. The main indications for CB reported by these authors were dystocia (difficult and protracted labour), scarred uterus, foetal distress, rupture or preuterine rupture, placenta previa, malpresentation, cephalopelvic disproportion (CPD), non-reassurance foetal heart and pregnancy-related hypertensive disorder, breech presentation and cord prolapse.^{3,6,11,17,18,22,23,48}

Table 5 shows the maternal and perinatal risk factors that lead to complications when performing CB. The main risk factors reported by these authors were chronic hypertension, cardiac disease, lung disease or other medical risk factors.^1,8 Furthermore, a study conducted in Burkina Faso reported postpartum and antepartum haemorrhage, stillbirth and infection.⁹ The ratio of maternal mortality by direct obstetric cause was 147.38 maternal mortality per 100 000 live births with a mean of 6.8 maternal deaths annually.^8,11,21 In addition, some incidents related to the procedure were also reported including bladder injury, intraoperative haemorrhages and the release of sutures.¹

The study populations in Cameroon and Nigeria reported a facility-based CB rate higher than the recommended rate of 10% – 15%, indicating overuse and a high proportion of CB costs related to real healthcare costs.^5,6 The facility-based CB rate in Ethiopia, with a rate of 29.7%, is significantly higher than WHO’s recommendation of 10% – 15%, contributing to significant maternal and perinatal morbidity and mortality and is also of concern.^7,8 A study in South Africa found that maternal mortality after CB is nearly three times higher than after VD. Haemorrhage resulting in hypovolemic shock was the primary cause of maternal deaths.⁹ According to the 2015/16 District Health Barometer, CB rates in South Africa’s public sector facilities increased from 15.1% in 2006 to 24.1% in 2015, with the biggest increases in Gauteng and the North-Western Cape.¹⁰

Emergency maternal healthcare is influenced by various factors, including inadequate healthcare facilities, lack of skilled staff, inequalities in access to maternity care and affordable intervention.^{3,4,6,8,11,12,13} Complications in maternal surgery, including intraoperative and postoperative bleeding, are common in many African countries, leading to maternal deaths.^12,14 Complications in childbirth, including CB, are primarily linked to risk factors such as infectious diseases, stillbirth and spinal anaesthetist, which can lead to cardiac arrest and hypoxia.^3,8,11,13,14 A study in Goma, Congo, found that prolonged labour led to vesicovaginal fistulae, and delayed EmOC contributed to 47.06% of maternal mortality.⁸ This study highlights that using guidelines to ensure appropriate indications, promoting access and providing quality surgical operations could reduce maternal death associated with CB.

Many SSA countries have inadequate healthcare systems because of insufficient facilities, finances and resources.¹⁵ Despite some countries adopting user-free maternal healthcare policies, access to maternal health services remains a significant challenge in SSA.^12,16,17 A study in Nigeria and Ghana found that despite user-free maternal healthcare policies, inequality in access to CB intervention persisted among women of varying sociodemographic backgrounds.⁴ A Ghanian study revealed that the wealth status of pregnant women significantly influenced the increase in the CD rate to 27.5%, compared to a rate of only 5% among poor women.⁴

In rural areas, access to maternal services is challenging because of inadequate health infrastructures and staff shortages. Improving service quality, particularly with skilled providers, is crucial to reduce maternal mortality associated with CB intervention.⁴ The morbidity and mortality associated with CB in SSA highlights the need for increased safety measures and strategies to address the inequalities to ensure a comprehensive and effective CB service.¹⁰ There is also a need for strategies for early patient evaluation to reduce primary CB and encourage vaginal births, which would reduce the rate of CB and associated complications.⁶

The low CB rate in Nigeria, despite free access, has contributed to a rise in foetomaternal mortality and morbidity. This highlights the need to address factors such as inadequate health facilities, poor referral, counter-referral systems and substandard equipment, which contribute to the low CB rate, in addition to the adoption of user-free maternal health services.¹⁸ The management of emergencies and referral cases for CB is a major challenge in much of SSA, highlighting the health systems’ challenges in CB management.^1,11,19

This review identified an urgent need for strategies to reduce maternal and perinatal mortality because of CB practices in SSA, especially in rural areas with inadequate health systems plagued by a shortage of qualified staff and inadequate resources. Poor health outcomes in obstetric emergencies can be attributed to inadequate resources, lack of skilled birth attendants, inappropriate facility distribution and inadequate referral systems.^20,21 Poor maternal outcomes following CB in SSA are results of inadequate training, poor use of national treatment protocols, unauthorised staff, poor patient records and lack of regular review of indications.¹³ Health systems should ensure accessible, high-quality EmOC, professional, skilled attendant maternity units and safe obstetric anaesthesia for every woman.¹⁴

The lack of access to safe CBs in some SSA counties contributes to a facility-based CB rate below the WHO’s recommended rate of 10% – 15%.²² Caesarean birth, when used appropriately, effectively prevents maternal and perinatal mortality, but it also poses risks from immediate and long-term complications.²³ Early access to maternity services, rapid diagnosis and referral to safe hospitals can decrease complications.²⁴ Many CB complications can be prevented by detecting potential risk factors during antenatal care and addressing issues such as quality care, availability of skilled health staff and adequate healthcare facilities.^25,26,27

Caesarean birth outcomes could be improved by enhancing health systems, such as accreditation of skilled obstetricians and availability of single anaesthetists for surgical emergencies, as reported in studies in Cameroon and Nigeria.⁵ Some countries have shown the political will to improve maternal services, such as Mozambique’s training of health providers and supervisors on the importance of timely referrals and supportive supervision.²⁸

The strength of this study is that it provides data from different types of studies evaluating health systems in SSA countries and their impact on the practice of CB. For example, a study conducted in a rural area in Nigeria reported that pregnant women travelled more than 20 km to attend a healthcare facility,¹⁵ while in Maputo, Mozambique, many training sessions were conducted with community health workers to ensure that they were clear about diseases or health concerns that need competent management, which included the referral of pregnant women for antenatal care and birth at healthcare facilities by a qualified personnel.⁶⁰

Other studies conducted in an urban area of Lagos, Nigeria and Douala, Cameroon, found that only 57% of pregnant women were seen by qualified health staff with EmOC available and skilled birth attendants present at birth.^6,13,49 Several health system points of quality and safety in low- to middle-resourced countries⁴¹ have been recognised, which include issues such as the absence of anaesthetic support, gaps in data quality (i.e. the name of an obstetrician who performed the CB and outcome of the procedure), insufficient equipment (this is associated with a delay to perform the procedure, anaesthetics complications and postoperative infections), gaps in training and supervision, lack of standardised protocols and skilled obstetricians as health system factors that influence the quality and safety of CB in many SSA countries.⁴² A study conducted in Ouagadougou, Burkina Faso, identified the availability of postoperative protocols (standing up early, removal of a urinary catheter and light meal on day 1) in the postoperative ward as contributing to better postoperative outcome, and additional training was provided to nurses for good implementation.¹⁷

The majority of SSA countries have a health workforce shortage, especially anaesthetists, and credentialing of the anaesthetist in the maternity unity was identified as an important health system activity to improve CB outcomes.^1,6,15,17, Studies conducted in Ouagadougou, Cameroon, identified that when doctors were trained in general and spinal anaesthesia to perform CD, CB outcomes improved.^9,17,40

The weaknesses of this scoping review include the following: