Exploring interventions to reduce blood loss during and after caesarean delivery in Africa

Background Women in Africa are fifty times more likely to die following caesarean delivery compared to high-income settings and blood loss during and after caesarean delivery is independently associated with mortality. We aimed to (i) identify interventions, and (ii) identify which interventions African clinicians and researchers recommend as feasible and effective to reduce blood loss during and after caesarean delivery. Methods (i) We conducted a systematic review and network meta-analysis to identify nonpharmacological interventions. We conducted a comprehensive search from database inception to 31 st December 2019, with no language restrictions. We included studies of women undergoing caesarean delivery, which assess nonpharmacological interventions, and report one of the study co-primary outcomes (blood loss [ml] or risk of post-partum haemorrhage [>1,000 ml]). We excluded retrospective studies, and study cohorts not representative of the general caesarean delivery population. (ii) We conducted a Delphi Consensus study, including obstetrics and anaesthesia providers from across Africa. Rounds one to three were online surveys, and round four formed a live online discussion. Findings (i) We included 51 studies in the network-meta-analysis, forming 13 distinct intervention groups. Thirty studies were not included in the meta-analysis and were synthesised narratively. On random effects model analysis, only three interventions had clinically significant findings, of which one had statistical significance. (ii) Twenty-eight interventions were considered highly effective and highly feasible. These interventions covered broad domains including community based; antenatal; perioperative; and health system strengthening interventions. Interpretation The published trials on the effect of non-pharmacological interventions on blood loss associated with caesarean delivery are inconclusive. There is a need for collaborative pragmatic trials to identify effective and generalisable interventions. The broad range of recommended interventions highlights the importance of a multifaceted systems strengthening approach to reduce morbidity and mortality associated with blood loss during and after caesarean delivery in Africa.