• Soha Sobhy, David Arroyo-Manzano, Nilaani Murugesu, Gayathri Karthikeyan, Vinoth Kumar, Inderjeet Kaur, Evita Fernandez, Sirisha Rao Gundabattula, Ana Pilar Betran, Khalid Khan, Javier Zamora, and Shakila Thangaratinam.
• Barts Research Centre for Women's Health, Queen Mary University of London, London, UK; Multidisciplinary Evidence Synthesis Hub, Queen Mary University of London, London, UK; Barts and the London School of Medicine and Dentistry, and WHO Collaborating Centre for Women's Health, Queen Mary University of London, London, UK.
• Lancet. 2019 May 11; 393 (10184): 1973-1982.

BackgroundUniversal and timely access to a caesarean section is a key requirement for safe childbirth. We identified the burden of maternal and perinatal mortality and morbidity, and the risk factors following caesarean sections in low-income and middle-income countries (LMICs).MethodsFor this systematic review and meta-analysis, we searched electronic databases including MEDLINE and Embase (from Jan 1, 1990, to Nov 20, 2017), without language restrictions, for studies on maternal or perinatal outcomes following caesarean sections in LMICs. We excluded studies in high-income countries, those involving non-pregnant women, case reports, and studies published before 1990. Two reviewers undertook the study selection, quality assessment, and data extraction independently. The main outcome being assessed was prevalence of maternal mortality in women undergoing caesarean sections in LMICs. We used a random effects model to synthesise the rate data, and reported the association between risk factors and outcomes using odds ratios with 95% CIs. The study protocol has been registered with PROSPERO, number CRD42015029191.FindingsWe included 196 studies from 67 LMICs. The risk of maternal death in women who had a caesarean section (116 studies, 2 933 457 caesarean sections) was 7·6 per 1000 procedures (95% CI 6·6-8·6, τ2=0·81); the highest burden was in sub-Saharan Africa (10·9 per 1000; 9·5-12·5, τ2=0·81). A quarter of all women who died in LMICs (72 studies, 27 651 deaths) had undergone a caesarean section (23·8%, 95% CI 21·0-26·7; τ2=0·62).InterpretationMaternal deaths and perinatal deaths following caesarean sections are disproportionately high in LMICs. The timing and urgency of caesarean section pose major risks.FundingAmmalife Charity and ELLY Appeal, Barts Charity, and the UK National Institute for Health Research.Copyright © 2019 Elsevier Ltd. All rights reserved.

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