Depending on the definition of morbidity following a caesarean section, the method of data collection, duration of follow up and the rate of intra and post-operative complications vary widely across the whole globe. A registry-based cohort study that was done in Finland, on maternal complications and obstetric risk factors for CS reported 27% CS related complications [1] where a complication rate of 21.4% was reported in Norway where a similar study design was used [2]. While a meta-analysis and systematic review that involved six articles from India on maternal-fetal outcomes in elective and emergency CS group reported a complication rate of 55.9% [3] when a retrospective case-control study was done in Tel Aviv, Israel 5.7% CS related complications was reported [4]. Complication rate of 13.3% was reported from a cross sectional study that was done in Nigeria [5] compared to a complications rate of 30.2% that was reported from a similar study design that was done in Rwanda [6].

Severe maternal morbidity and mortality are mostly encountered among women who underwent an emergency caesarean section as compared to the planned caesarean section [2] [3]. Preeclampsia, eclampsia, increasing maternal age, preterm delivery especially when the gestational age is <30 weeks, previous abdominal surgery (other than CS), type 1 diabetes, multiple pregnancy and uterine rupture have also been documented as risk factors for caesarean section related complications [1]. Maternal obesity (BMI > 35 kg/mm²) has also been found to be highly associated with wound complications whereby vertical skin incisions have a 7 times higher chance of wound infection and wound separation compared to the transverse skin incision [7].

After exclusion of pre-existing morbidity, CS births have a 4 - 5 higher fold of morbidity and mortality as compared to vaginal delivery [8] [9]. CS delivery has been found to be related to blood transfusion, endometritis, superficial surgical site infection, haemorrhage, injury to the pelvic organs, thromboembolic disorders and anaesthesia related complications [5] [10] [11] [12] [13] [14]. Whereby Maternal mortality (MM) is related to CS is about 6 - 13/100,000 deliveries in the high resource countries and 7.6/1000 deliveries in low and middle-income countries respectively [10] [14].

In long term, caesarean section delivery is associated with abnormal placentation, uterine rupture in the subsequent pregnancy, adhesions, unexplained stillbirth, preterm birth especially when the previous CS was done during the second stage of labour and scar complications which includes postmenstrual spotting, endometriosis, uterine scar pregnancy, numbness and pain [14] [15].

This study aims to determine the rate of caesarean section complications, characterize their timing and identify the risk factors for maternal complications among women delivered at KCMC hospital.

A total of 2310 deliveries occurred at KCMC during the study period of which 1138 had Caesarean section. This makes a caesarian section rate of 49.1% among those delivered by CS, five women were excluded because uterine rupture was found intraoperatively, thus 386 participants were enrolled in the study. All of them agreed and signed their consent; this gives a participation rate of 100%.

During the study period, 49.1% of women were delivered by caesarean section, out of these 27.5% had CS related complications. The most common immediate complications (with 24 hours of CS delivery) were anaesthesia-related complications, blood transfusion and PPH. While the most common “early complications” (within 24 to 72 hours of the operation); were puerperal sepsis, anaesthesia-related complications and blood transfusion. Longer duration of surgery was significantly associated with all the complications.

In this study, the rate of caesarean section related complications among women delivered by CS at KCMC hospital was 27.5%, these findings were the same as the findings from Finland (27%) and Norway (24.1%) [17]. This can be explained by the fact that all these studies were done in large obstetric units in referral centers which receive high risk and complicated patients and the same duration of follow-up was used. The rate of complications that were observed in this study is in contrast to the rate that was observed in India (55.1%), Israel (5.7%) and Nigeria (13.3%) [3] [5] [18]. This can be explained by differences in study designs and methods that were used, for example, a retrospective cross-sectional study that was done in large tertiary hospital in Nigeria, included all CS delivery that was only done during the day where most of the team members are available and very energetic, showed a far much lower complication rate. However, this diversity implies that just like any surgery, CS delivery is prone to complications and this cuts across high income to low-income countries.

Most common complications that were encountered within the first 24 hours of CS (“immediate complications”) were found to be Anaesthesia related complications, blood transfusion and PPH. These complications were more common in the emergency CS group compared to the elective CS group. These findings were supported by studies from Israel [18] and Nepal and Saudi Arabia [19] [20]. These similarities can be explained by the fact that all these studies were done in referral and tertiary hospitals which receive women from lower facilities with complications like prolonged labour which makes them prone to hemorrhage intra operatively and post operatively.

This study showed that puerperal sepsis, anaesthesia-related complications and blood transfusion were the most common “early complications” encountered after caesarean section. These findings were in line with studies from Israel where endometritis was found to be the most prevalent complication, reported to occur on day two and three [18]. These findings emphasise the benefit of providing prophylactic antibiotic to every parturient that delivers by CS since Caesarean delivery is a known risk factor for endometritis, it also emphasizes that CS should be done only when indicated.

Longer duration of surgery (>60 minutes) was found to be associated with all complications, which was similar to findings from cohort studies that were done in Norway and Nigeria [21] [22]. However, findings from this study contrast with findings from Finland, India, Norway, Israel and South Africa which showed emergency CS, cervical dilatation, maternal characteristics and fetal factor were associated with all complications [17] [18] [23]. However, this serves as a continuous alarm to physicians to modify the already known risk factors before surgery to minimize incidences of complications while optimizing good maternal-fetal outcomes.

Pre-operative anaemia was also found to be significantly related to a blood transfusion during or after surgery, this finding is similar to findings from Nigeria, India and U.S.A [24] [25] [26] This is because caesarean section is associated with significant blood loss as compared to vaginal delivery. Hence small amounts of blood loss intra-operatively in women with preoperative anaemia can produce symptoms and signs of anaemia which will necessitate blood transfusion. Therefore, care providers should make every effort to optimize the haemoglobin levels of every pregnant woman before delivery.

Grand multiparity was also found to be positively and significantly associated with blood transfusion intra and/or postoperatively. This finding was similar to findings from Nigeria and Saudi Arabia [20] [27]. This can be explained by the fact that grand multiparity has been known to be a risk factor for pre-operative anaemia, abnormal placentation and post-partum haemorrhage (PPH) due to uterine atony. All of these are significant predictors for blood transfusion. However, literature to contrast these findings was not found. Hence continuous education on family planning must be done to reduce risks that are associated with grand-multiparity.

This study has highlighted the magnitude of CS delivery-related complications at KCMC hospital. It also highlights the risk factors for the most prevalent complications.

However, this study was prone to recall bias, especially when participants were supposed to provide information on their past medical and surgical history.

As well there may be under-reporting of the caesarean section related complications since participants were not followed up for other possible early complications following hospital discharge. This is because most of the time our patients get discharged from the hospital on the third-day post caesarean section if there are no complications.

During the study period, 27.5% of the study participants had one or more CS-related complications, most of the complications being reported in the first 24 hours of the operation. Longer duration of surgery, grand multiparity and pre-operative anaemia were associated with complications. Therefore, CS should be performed when there is a strong obstetric indication. Health facilities and practitioners should aim at reducing the risks like anemia and grand-multiparity during pre and antenatal visits.

I would like to acknowledge KCMC hospital administration for allowing me to conduct this study in its hospital. Above all would like to appreciate all women who consented to participate in this study.

All authors contributed to the study’s conception and design. Material preparation, data collection and analysis were performed by Glory Mangi. The first draft of the manuscript was written by Glory Mangi, Patricia Swai and Werner Maokola. Pendo Mlay and Olola Oneko commented on the previous versions of the manuscript. All authors have read and approved the final manuscript.

This study was conducted in line with the principles of declaration of Helsinki. An ethical clearance certificate No. 2338 was obtained from Tumaini University College Research Ethical Committee before the initiation of the study. Finger print was used for illiterate women. Codes and hospital numbers were used instead of patient’s names. It was emphasized that participation in the study was voluntary and that the woman could withdrawal from the study at any time if she wished.

Written informed consent was obtained from all study participants.

Authors have no financial or non-financial interest to disclose.

Mangi, G., Mlay, P., Oneko, O., Maokola, W. and Swai, P. (2022) Postoperative Complications and Risk Factors among Women Who Underwent Caesarean Delivery from Northern Tanzania: A Hospital-Based Analytical Cross-Sectional Study. Open Journal of Obstetrics and Gynecology, 12, 243-257. https://doi.org/10.4236/ojog.2022.124023

APH: Antepartum haemorrhage; CPD: Cephalo-Pelvic Disproportion; CRP: C-Reactive Protein; CS: Caesarean Section; ERCD: Elective Repeat Caesarean Delivery; HDP: Hypertensive Disorders of Pregnancy; HIV: Human Immunodeficiency Virus; MM: Maternal mortality; MNM: Maternal Near Miss; PPH: Post-Partum Haemorrhage; SSA: Sub-Saharan Africa; SSI: Surgical Site Infection; TOLAC: Trial of Labour after Caesarean Section; WHO: World Health Organization.