Ethics and consent

Ethics approval was provided by the Human Research Ethics Committee of the Faculty of Health Sciences of the University of Cape Town, South Africa (HREC 187/2020), and by the Oxford Tropical Research Ethics Committee (524–20). Collaborators were provided with an information sheet and online consent was obtained at the beginning of each round.

Data collection

The study was conducted in English and French. Study data from rounds one to three were collected and managed using REDCap, a web-based data capture software application [9]. Round four was held via ZOOM Video Communications Version: 5.0.5, an online video conferencing platform.

Participant selection

To identify African obstetricians and anaesthetists considered leaders in the field of obstetric care and obstetric anaesthesia, we asked National leaders from previous APORG studies—the African Surgical Outcomes Study [5] and/or the African Surgical OutcomeS-2 Trial [10] to identify and invite experts from within their respective countries. We encouraged the participation of two obstetric and anaesthesia providers from each country.

Delphi process

Round four.

Round four was an online discussion. Interventions were presented to participants based on the summarised group scores from round three. Interventions with a median score of 1–3 in either effectiveness or feasibility domain were excluded and not considered in round four. Interventions with a median score of 7–9 in both domains were recommended and included in the final list of interventions. The aim of round four was to gain consensus on whether to upgrade any of the ‘potential interventions’ with a median score of 4–6 in one or more domain to the final list of recommended interventions. The study process is summarised in Fig 1.

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Fig 1. Study process flow diagram.

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Direct interventions—Antenatal care and assessment

Anaemia during pregnancy is associated with an increased risk of post-partum haemorrhage; the risk of maternal mortality in women with severe anaemia has an odds of 2.36 when compared to women without the condition [11]. Early identification of anaemia through screening would facilitate blood management programmes.

Routine preoperative risk assessment and risk stratification for peripartum haemorrhage may facilitate preoperative optimisation and/or the implementation of strategies to mitigate risks in the perioperative period. Current guidance on haemorrhage risk stratification is defined by the Royal College of Obstetricians and Gynaecologists, and may not be applicable in its entirety in low resource settings [12].

Midwives play a critical role in providing antenatal care, including the assessment of risk factors. A modelling study projected a 39% reduction in maternal mortality in low human development index (HDI) countries, and a 43% reduction in maternal mortality in low-to-medium HDI countries by 2035 if midwife-delivered interventions were to be scaled up by a ‘substantial amount’, defined as a 25% increase in coverage every five years [13].

Comprehensive antenatal care presents an opportunity to provide maternal education on the self-recognition of signs and symptoms of peripartum haemorrhage. A study in Burkina Faso, Ghana and Tanzania showed that a third of women were not counselled on the danger signs of a high-risk pregnancy, and the proportion of women retaining the counselled information was generally low [14]. Context-sensitive and tailored methods of relaying information on the self-recognition of danger signs may reduce the ‘phase one delay’ in deciding to seek healthcare [15].

Direct interventions—Perioperative care

Use of surgical safety checklists have been associated with decreased postoperative mortality and decreased surgical complication rates. A meta-analysis of randomised trials assessing the effect of a surgical safety checklist found a statistically significant reduction in postoperative mortality, yet none of the included studies were from Africa [16]. Despite the simplistic nature of checklists, there are inherent challenges to implementation within complex health systems. An analysis of pooled data from five prospective cohort studies indicated significant variation in uptake of the World Health Organisation (WHO) Surgical Safety Checklist (SSC) across the world. Surgical patients in the African Surgical Outcomes Study were exposed to the SSC in 57.1% of operations [5], below the pooled global average of 75.4% [17]. The WHO SSC was significantly less likely to be used in obstetric and gynaecological surgery compared to abdominal surgery in the pooled global analysis [17]. Given that use of the WHO SSC is low in Africa and in obstetrics, modified SSCs that are tailored to incorporate factors specific to caesarean delivery and practice in Africa, with context-sensitive implementation strategies, may have better uptake and utilisation. A study in a rural Rwandan hospital implemented a modified WHO SSC, adapted for low resourced settings [18]. Following implementation of the checklist, there was an increase in the documentation of estimated blood loss, reduced hospital length of stay, and an increase in the administration of antibiotics prior to incision. During the study period, the checklist was used in over 80% of procedures [18]. This indicates the importance of developing context-sensitive implementation strategies alongside checklists tailored for differing surgical specialties and environments.

ASOS showed that the high mortality associated with caesarean delivery across Africa is likely associated with ‘failure to rescue’ [6]–defined as the hospital death rate following a postoperative adverse outcome or complication. Women in Africa are three times more likely to experience a complication following caesarean delivery, yet are 50 times more likely to die than women in high-income settings. This indicates a failure to rescue rate 17 times higher in Africa than in high-income settings [6]. The implementation of interventions which improve a health system’s ‘capacity to rescue’, may reduce the failure to rescue associated with caesarean delivery.

Delphi experts identified interventions which form a framework to improve capacity to rescue (Fig 3). The framework divides interventions into two groups: (i) early detection of the complication, and (ii) timely and appropriate management.

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Fig 3. Improving the capacity to rescue intervention framework.

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For ‘early detection of the complication’, the expert group recommend both ‘early and increased surveillance of vital signs in the perioperative period, possibly in a dedicated environment’ and ‘routine use of modified early obstetric warning score in the postoperative period, or routine active monitoring for haemorrhage e.g., shock index’. Given the challenges in estimating volume of blood loss, and that blood loss is often underestimated on visual assessment, vital signs are a critical indicator of haemodynamic instability [19]. The group highlighted the importance of validated objective scoring systems, enabling prompt and appropriate escalation of care. It is important that scoring systems are applicable to patient cohorts in Africa, and are feasible for use in low-resource settings. Due to the normal physiological changes of pregnancy, which include an increased blood volume, women may experience a prolonged period of apparent physiological compensation, prior to rapid deterioration [20]. General scoring systems may therefore be inappropriate in the obstetric population, and use of an obstetric-specific modified early obstetric warning score may be more effective. Modified early obstetric warning scores have been developed for- and embedded within clinical practice in high-income settings [20]. There is a need to develop a modified early obstetric warning score specific for use in a low-resource setting, and validated on local caesarean delivery populations. The shock index is a rudimentary tool based upon the measurement of systolic blood pressure and heart rate. Despite its simplicity, shock index is a good predictor of blood transfusion and admission to an intensive care unit following haemorrhage [19]. The Delphi group highlighted the importance of ‘routine’ use, which emphasises the need to embed such interventions within patient safety culture, as opposed to intermittent use at the discretion of the healthcare provider. According to the African Surgical Outcomes Study, inadequate human and physical resources are key factors in the increased rate of failure to rescue across Africa. User-friendly objective surveillance scores may be utilised by a range of healthcare personnel, and not limited to use by trained doctors and nurses. Given the sparse workforce density of surgical, anaesthesia, nursing and midwifery providers across Africa, such tools may be impactful.

The second component of the failure to rescue interventions framework focusses on timely and appropriate management of complications. Recommendations refer to the ability to perform clinical interventions such as: uterine massage and bimanual compression; hysterectomy and uterine artery ligation; B-lynch and compression sutures; and balloon tamponade. These are life-saving procedures which require trained personnel and physical resources. Uterotonic agents and tranexamic acid have been proven to be effective for the treatment of postpartum haemorrhage, though supply may vary in many low-resource settings [21]. Emergency blood products are a scarce resource across Africa. A review estimated that 26% of obstetric haemorrhage-related death in Africa was due to lack of available blood transfusion [22]. Rapid access to emergency blood transfusion is life-saving, but relies on a complex health system for its procurement. The establishment of a peripartum haemorrhage package implies the availability of necessary emergency resources, and the logistical ease of timely access. The use of emergency packages/bags/trolleys for time-critical situations is well established in resuscitation scenarios. The package may also contain protocols. The implementation of checklist-based haemorrhage protocols are associated with a reduction in maternal morbidity [23]. Obstetric haemorrhage packages/bundles exist [24, 25] though the development and assessment of packages/bundles contextualised for caesarean delivery in low-resource settings is needed. The ‘early involvement of anaesthesia providers in the management of patients at risk’ acknowledges the importance of the early escalation of care and the vital role of anaesthesia providers in the management of haemodynamically unstable patients.

The range of recommended interventions within the failure to rescue framework may disrupt the cascade of events that occur from complication to death, and increase the capacity to rescue following caesarean delivery in Africa.

Indirect interventions—Community based

The expert group recommended ‘Community information, education and communication regarding reproductive health’. Multiple community factors and perceptions regarding obstetric complications have been identified as barriers to utilising emergency obstetric care in Africa. Community barriers to accessing obstetric care identified in the literature include: socio-cultural factors, confidence in alternative practices, negative views of healthcare services, distrust in health care workers, stigma regarding seeking healthcare, anticipating self-improvement without seeking healthcare, fear of caesarean delivery and blood transfusion, and preference for delivery in the home environment [26]. Deciding to seek care may be impacted by perceptions of the pregnant woman, their family and the wider community, and thus information, education and communication-based interventions aimed at a wider community level may reduce the ‘phase one delay’, in which time is spent deciding whether to seek care [15].

Both community information and education, and access to contraception and family planning, form critical components of the Sustainable Development Goal 3.7: “Target 3.7: By 2030, ensure universal access to sexual and reproductive health-care services, including for family planning, information and education, and the integration of reproductive health into national strategies and programmes” [27]. Modern contraceptives form a vital primary prevention strategy to reduce maternal mortality by averting maternal mortality directly (by decreasing the total fertility rate and the absolute number of maternal deaths) and indirectly (by reducing the frequency of high-risk, high-parity pregnancies) [28]. Importantly, Africa has the lowest prevalence of contraceptive use, and the highest unmet need for family planning in the world [29]. A universal, community based approach to improve access to and uptake of modern contraceptives and family planning services may therefore be particularly effective.

Indirect interventions—Health system-strengthening

Multidisciplinary simulation and team training designed to optimise team performance, may improve team morale, communication and utilisation of patient safety protocols. Context-sensitive Non-Technical Skills for Surgeons (NOTSS) training, with emphasis on specific challenges faced within various resource settings, have been developed and feasibility-tested in Rwanda [30].

Delays have been well described as a contributing factor to maternal mortality [15]. This Delphi process recommended a focus on interventions which reduce delays in receiving care once at the healthcare facility, and establishing smooth and timely referral systems between levels of care. This may reflect the make-up of the Delphi group, which recommended addressing delays which can be more directly influenced by obstetric and anaesthesia providers. A meta-analysis of maternal mortality after caesarean delivery found that women are more likely to die at teaching and tertiary hospitals [31]. National audit data from the National Committee on Confidential Enquiries into Maternal Deaths in South Africa show that many caesarean deliveries were performed at district hospitals and when complications arose women were subsequently referred to higher levels of care (regional, tertiary and national hospitals), where they then died [32]. These data emphasise the need to improve referral systems, to ensure timely referral and transfer of women at high risk of peripartum haemorrhage. There may be a role for technological interventions to improve communication between healthcare workers at different levels of care, an example being the model adopted by SURG-Africa—implementing WhatsApp group support networks to guide appropriate referrals between levels of care [33].

Emergency caesarean delivery may be required at any time of day. The ability to provide a safe 24-hour caesarean delivery service may reduce delays in receiving care and unsafe referrals between healthcare facilities. In addition, improving 24-hour access to caesarean delivery may contribute to increasing the caesarean delivery rate across Africa, to rates associated with a reduction in maternal mortality [3, 4].

Minimum training standards should be enforced for healthcare providers. A lack of appropriately trained doctors and nurses continues to be the most frequently cited avoidable risk factor for maternal mortality in South Africa [32].

The expert group identified the importance of ‘advocating to key stakeholders about the importance of reducing maternal morbidity and mortality related to peripartum haemorrhage’. Many of the recommended interventions are varied, inter-disciplinary and reflect a system strengthening approach, in addition to a clinician-focussed approach. Strengthening of healthcare systems is complex and requires buy-in from key stakeholders, with substantial upstream support at government and policy-maker level. Frameworks which measure the impact of such interventions within the wider healthcare system, may be of use [34].

The rising number of caesarean deliveries across Africa, combined with the unacceptably high proportion of women who die following this procedure [4, 6] necessitates urgency when advocating for interventions to strengthen health systems, to prevent avoidable deaths of mothers across the continent.

Strengths

This was an African continental consensus study representing 24 countries, with a high response rate, and with representation from anaesthesia and obstetric providers. Rounds one to three were conducted in French and English to increase accessibility and participation.

Limitations

No patients, midwives or public health specialists were involved in the Delphi process. Despite this, the suggested interventions cover broad health domains. The involvement of these stakeholders may have widened the scope of recommendations.

Since the Delphi study was conducted online, this study is biased towards receiving data from those with access to email and the internet, and the majority of input was received from participants working in tertiary healthcare settings. This may have resulted in the omission of critical insights from those working in district and rural healthcare facilities.

Conclusion

This Delphi study recommends interventions considered both effective and feasible in reducing haemorrhage during and after caesarean delivery in Africa. A multi-layered implementation strategy, which includes immediately developing a perioperative caesarean delivery bundle of care, in addition to the implementation of longer-term public health measures may have a profound impact on maternal mortality in this under-resourced continent.