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(VBAC), but advocate for safe practice of the latter. We believe in the need for good justification beyond the rising caesarean section (CS) rate, for continued exposure of women to substandard delivery practices. Most of the observations made by the authors concerning the status of CS rates and its attendant risks in lowresource settings are true; unfortunately, the authors dwell on this issue but our main concern is with the safety of VBAC. The institutions reporting high CS rates in the region are mainly private or university-based with the capacity to offer safe VBAC. Our concern is with those maternity units in sub-Saharan Africa that cannot guarantee safe VBAC, yet encourage the practice.3 We aim to help the accoucheur in choosing the ‘lesser evil’ between ERCS with its risks in subsequent pregnancies or substandard VBAC with the immediate risk of haemorrhage, sepsis and maternal death. Boulvain et al.4 in their response to our commentary correctly state that the risk of placenta praevia and accreta increases exponentially with the number of CS. However, it is also true that the risk of severe haemorrhage and postpartum endometritis in women attempting VBAC is higher (1.7% and 2.9%).5 If you factor in the risk of severe haemorrhage resulting from placenta praevia in women with one or two previous CS, the absolute risk increases to over 2%. Uterine rupture is often overemphasised yet severe haemorrhage in women undergoing VBAC could be a serious independent risk. We argue that haemorrhage and sepsis are the leading causes of maternal mortality in sub-Saharan Africa and encouraging a substandard practice exposes these women to even higher risk of severe morbidity and death. In our experience implementation of institutionalised care pathways and VBAC protocols in sub-Saharan Africa is possible if the minimum resources are made available.6 Indeed professional bodies such as the Royal College of Obstetricians and Gynaecologists, American College of Obstetricians and

Gynecologists demand stringent institutional criteria before VBAC. In sub-Saharan Africa, monitoring of mothers in labour is random, compounded by missing details of the previous CS, lack of obstetric ultrasound and lack of capacity to handle complications, VBAC becomes dangerous. We do not intend to stimulate higher CS rates as the authors insinuate but to get health providers to prioritise maternal safety. The authors rightly state that a scarred uterus in sub-Saharan Africa could be a ‘death sentence’. We would also like to point out that delivery in most health facilities in sub-Saharan Africa does not necessarily mean supervised delivery. A woman with a scarred uterus labouring in hospital is as much at risk of uterine rupture, haemorrhage and death as someone labouring at home. This makes ERCS a safer alternative. In conclusion, we would like to encourage colleagues to offer the same standard of care to all women regardless of their geographical location. Previous successes with substandard care do not justify continuity of unsafe practices as this raises considerable ethical and legal concerns.

Conflict of interest Both authors are full time university employees and do not engage in private practice as insinuated by the authors. We therefore have no competing interests. &

References 1 Mola G, Verkuyl DAA. ‘To VBAC or not to VBAC’. BJOG 2014;121:908. 2 Wanyonyi SZ, Ngichabe SK. Safety concerns for planned vaginal birth after caesarean section in sub-Saharan Africa. BJOG 2014; 121:141–4. 3 Reports and Service Provision evaluation survey in Sub Saharan Africa. [www.measuredhs .com/Publications/]. Accessed 6 January 2014. 4 Boulvain M, Benski A-C, Jastrow N. Commentary on ‘Safety concerns for planned vaginal birth after caesarean section in sub-Saharan Africa. BJOG 2014;121:144. 5 Landon MB, Hauth JC, Leveno KJ, Spong CY, Leindecker S, Varner MW, et al. Maternal and

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perinatal outcomes associated with a trial of labour after prior caesarean delivery. N Engl J Med 2004;351:2581–9. 6 Wanyonyi SZ, Karuga RN. The utility of clinical care pathways in determining perinatal outcomes for women with one previous caesarean section; a retrospective service evaluation. BMC Pregnancy and Childbirth 2010;10:62.

SZ Wanyonyia & SK Ngichabeb a

John Radcliffe Hospital, Nuffield Department of Obstetrics & Gynaecology, University of Oxford, Oxford, UK; bDepartment of Obstetrics and Gynaecology, Aga Khan University, Nairobi, Kenya

Accepted 15 January 2014. DOI: 10.1111/1471-0528.12711

Safety concerns for caesarean section

Sir, We read with interest the article by Wanyonyi et al.,1 published in the BJOG special issue on ‘Management of pregnancy after caesarean section’. At the same time, we were shocked to find several flaws in the paper. First, the authors, who are concerned about the safety of vaginal birth after caesarean section (VBAC), hardly show any concern about the safety of caesarean section in low-income countries. In a recent audit of caesarean sections in a referral hospital in a low-resource setting, we observed five maternal deaths in 268 consecutive sections (1.9%). Many women do not want to be delivered by caesarean section, and do everything to escape another section. Elective repeat caesarean section will only increase the morbidities of multiple scars in a population where women generally have many babies and where blood is scarce. A case fatality rate of 1.9% versus 0.05% in high-resource settings must have consequences for the indication to perform the operation, not only for the first, but also for repeat operations. In complete opposition to the authors’ statements, VBAC should be

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encouraged everywhere, and also in settings with such high complication rates. A second important flaw is the statement that ‘the overall rate of caesarean section in sub-Saharan Africa is still very low’. A population-based caesarean section rate will obviously be low when more than 60% of women do not give birth in places where caesarean section can be performed. But facility-based rates have increased at a worrying pace over the past decade, very often on dubious or even plainly wrong indications.2 Nowadays, in many hospitals caesarean section will be performed for ‘obstructed labour’ even with intact membranes. Inefficient uterine action in primigravid women is seldom treated with oxytocin augmentation, and instrumental vaginal delivery in the second stage of labour has become almost non-existent. From our experience, in many hospitals in East Africa VBACs are seldom tried, although this could be attempted safely in such clinics, where caesarean section can be performed at any time of day. Doctors or associate clinicians (in most places one will not find obstetricians), would have to be present in the labour ward when women have their trial of scar, however. Provided that clinicians in labour wards take their responsibility, this practice would not increase morbidity and mortality – to the contrary. Another issue related to the relative risk and high rate of caesarean section is that decision-making and performance of caesarean section in teaching hospitals are generally made by the least experienced clinicians available, often intern doctors and junior clinicians. This calls for much more supportive supervision in the often extremely busy labour wards in sub-Saharan hospitals. For all these reasons Africa should not follow the American dictum of ‘once a caesarean, always a caesarean’. Infering wrongly from a random shop around the medical literature is not a reliable basis for policy change.

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Disclosure of interests We declare that we have no conflict of interest. &

References 1 Wanyoni SZ, Ngichabe SK. Safety concerns for planned vaginal births after caesarean section in sub-Saharan Africa. BJOG 2014;121:141–4. 2 Maalǿe N, Sorensen BL, Onesmo R, Secher NJ, Bygbjerg IC. Prolonged labour as an indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals. BJOG 2012;119:605–13.

J van Roosmalen & T van den Akker Department of Obstetrics, Leiden University Medical Centre, Leiden, the Netherlands Accepted 29 January 2014. DOI: 10.1111/1471-0528.12747

Authors’ reply Sir, We would like to thank the authors for their contribution to the topic. We agree that caesarean section is not entirely safe, and that the case fatality rate could indeed be higher in sub-Saharan Africa than it is estimated. It is also true, however, that the morbidity associated with vaginal birth after caesarean section (VBAC) could be significantly higher. It is therefore incumbent on clinicians to recommend delivery options that are safe in light of the available resources. Unlike VBAC, elective repeat caesarean section (ERCS) is planned, and hence the clinician has ample time to prepare for any complications. The likelihood of morbidity arising from an elective operation is therefore much lower than in an emergency situation,1 yet it is difficult to predict which women undergoing VBAC may eventually need an emergency caesarean section. Unfortunately, most women in sub-Saharan Africa present late in labour after unsuccessful attempts to deliver at home. Managing these women, especially those with scarred uteri, without proper monitoring could be disastrous. Considering that most

facilities are far from achieving a midwife/patient ratio that allows for adequate intrapartum monitoring, ERCS could avert such eventualities. We do not favour caesarean section per se, and even noted in our article measures to reduce primary caesarean section rates. We do agree with the authors on the need for proper decision making, active involvement of senior clinicians at all levels of management, and the judicious use of oxytocin as other measures to avoid unnecessary caesarean section. We also advocate for cost-effective models that would make caesarean section readily available and safe.2 The reluctance of women to have repeat caesarean section is down to several factors, ranging from previous experiences, poor outcomes attributed to the primary surgery, ignorance, unfounded fear, lack of confidence in the healthcare system, and high cost of the operation. Efforts should therefore be made to inform women on the implication of a previous scar and resources availed to boost their confidence in the health systems, rather than assuming ‘that is how they are’. Interventions should not be based on speculations without addressing the root cause. The facility-based caesarean section rates in sub-Saharan Africa are still low, and the operation is often performed too late, when it is least beneficial.1 There is therefore no rationale to advocate for lowering this rate any further. Instead, the operation should be made more available and safer. Fear for VBAC among practitioners in East Africa is triggered by the suboptimal conditions under which they work. Although they may be aware of the prerequisites for safe VBAC, most cannot offer it because of a lack of intrapartum monitoring, inadequate human resources, and deficient healthcare systems.3 Those who choose to practice under these conditions are put in a defenceless position should complications arise. Finally, we would like to emphasise that we do not subscribe to the dictum of ‘once a caesar always a caesar’, but

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Safety concerns for caesarean section.

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