Task shifting cesarean sections in low- and middle-income countries: A systematic review and meta-analysis

Abstract

Background: Safe and timely access to cesarean section (CS) in low- and middle-income countries (LMIC) remains a significant challenge.

Objectives: To compare maternal and perinatal outcomes of CS by non-physician clinicians (NPCs) versus physicians in LMIC.

Search strategy and selection criteria: A systematic search of Ovid MEDLINE, EMBASE, Cochrane Library (including CENTRAL), Web of Science, and LILACS was performed from inception to January 2022.

Data collection and analysis: Data were extracted by two independent reviewers and meta-analysis was performed when possible.

Main results: Ten studies from seven African countries were included. There was no significant difference in maternal mortality for CS performed by NPCs versus physicians (odds ratio [OR] 1.09, 95% confidence interval [CI] 0.56-2.14, P = 0.8, I² = 70%, P < 0.05, eight studies, n = 20 711) or in perinatal mortality (OR 1.18, 95% CI 0.86-1.61, P = 0.3, I² = 88%, n = 19 716). Despite heterogeneous clinical settings between providers, there was no difference in the rates of wound infection or re-operation, although there was a higher rate of wound complications (such as dehiscence) in the NPC group (OR 1.89, 95% CI 1.21-2.95, P = 0.005, n = 6507).

Conclusions: NPCs have comparable maternal and neonatal outcomes for CS compared with standard providers, albeit with increased odds of wound complication.

Prospero registration: CRD42020217966.

Keywords: cesarean section; low-income country; maternal morbidity; maternal mortality; middle-income country; non-physician clinician; perinatal mortality; postoperative complication; task-shifting.