Safety concerns for planned vaginal birth after caesarean section in sub-Saharan Africa

For more than 30 years, planned vaginal birth after caesarean section (VBAC) has been offered as an option to women with prior caesarean section. This was mainly driven by the need to lower the rising rates of caesarean section. A consensus meeting between the National Institutes of Health (NIH) and World Health Organization (WHO) concluded that the rate of caesarean section was too high, and VBAC was therefore seen as an acceptable alternative to elective repeat caesarean section (ERCS). This approach was partially motivated by the reported success rates and safety of VBAC.1 At the time, this statement was applicable to developed countries, as resource-poor areas were yet to register significant caesarean section rates to warrant such interventions; however, recent demographic data indicate that the practice of planned VBAC is now prevalent in most maternity units in Africa.2,3 The deficiencies in delivery of health services in most low-income countries are common knowledge. The region also bears the greatest burden of maternal and perinatal morbidity and mortality. Therefore, the main concern is whether planned VBAC can be safely offered to women in this region, bearing in mind the scarcity of essential resources, without further worsening the already poor perinatal outcomes. Unfortunately, most of the information on the subject is derived from demographic health surveillance data, and consequently the outcome of VBAC in the region is poorly understood.3 The overall rate of caesarean section in sub-Saharan Africa (SSA) is still very low; however, it remains the most common operation performed in the region, and there is an upward trend as more women gain access to this lifesaving procedure.3 Consequently, the proportion of women with scarred uteri as a result of caesarean section is inevitably on the rise. Considering the high birth rates, bigger family size, and low contraceptive coverage in this region, the chances of these women having subsequent pregnancies is very high.2 Clinicians and policy makers therefore need to be well prepared to advise and formulate appropriate delivery plans suitable for these women without compromising their safety. Whereas planned VBAC may be an option, it is not as safe as it was originally thought to be. To the contrary, evidence indicates that ERCS is safer than unsuccessful VBAC. The major maternal complications associated with unsuccessful VBAC include uterine rupture, hysterectomy, venous thromboembolism, haemorrhage, transfusion requirements, visceral injury, and maternal death. Most of these complications can be averted by offering the woman an ERCS. Compared with those who opt for ERCS, women undergoing planned VBAC are at a greater risk of severe haemorrhage requiring blood transfusion (170/10 000 versus 100/10 000) and postpartum endometritis (289/10 000 versus 180/10 000). This equates to an increase in transfusion needs and postpartum uterine infection of 0.7 and 1.1%, respectively.4 Of concern is the fact that obstetric haemorrhage and infection account for almost half of maternal deaths in SSA, and efforts to reduce this have been elusive for decades.5 Further data from SSA indicate that more than 15% of emergency caesarean sections performed on scarred uteri will require blood transfusion, and these needs are doubled in the event of uterine rupture.6 Most facilities in low-income countries lack sufficient blood products, and therefore allowing women to undergo VBAC will further increase morbidity and mortality, rather than prevent it. This situation is further worsened by poor antenatal care and suboptimal birth preparedness. For instance, it is known that the incidence of placenta praevia is high in women with previous caesarean section. This is a well-recognised cause of antepartum haemorrhage, with potential risk of fatality.7 Most women in low-income..