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Cesarean and maternal mortality: Risk factor and indication bias
John Jairo Zuleta-Tobón1,2, Juan Sebastián López-Martínez3
1Especialista en Obstetricia y Ginecología Magister en Epidemiología, Medellín, Colombia.
Summary
Cesarean sections show a higher maternal death rate than vaginal deliveries. Careful case-by-case analysis is crucial to understand the true influence of cesarean sections on maternal mortality, accounting for indication bias.
Area of Science:
- Obstetrics and Gynecology
- Public Health
- Epidemiology
Background:
- Maternal mortality remains a significant public health concern globally.
- Cesarean section is a common obstetric procedure, but its association with maternal death requires careful evaluation.
- Indication bias can complicate the interpretation of studies linking cesarean sections to maternal mortality.
Purpose of the Study:
- To investigate the relationship between cesarean section and maternal death.
- To assess the impact of indication bias on the observed association between cesarean section and maternal mortality.
Main Methods:
- Retrospective case series analysis of maternal deaths involving cesarean section in Antioquia, Colombia (2011-2020).
- Classification of the association between death and cesarean section as directly related, associated, or not associated by independent researchers.
- Analysis of underlying conditions and indications for cesarean section to identify potential biases.
Main Results:
- The maternal mortality rate was higher for cesarean sections (48.6/100,000) compared to vaginal deliveries (17.9/100,000), yielding a crude relative risk of 2.7 for cesarean sections.
- A significant proportion of maternal deaths (58.9%) were found to have no direct association with the cesarean section itself.
- Reasons for no association included critical illness from obstetric complications, underlying medical conditions, or pregnancy-related conditions predating or independent of the cesarean procedure.
Conclusions:
- The crude association between cesarean section and maternal death is influenced by indication bias.
- Accurate assessment requires detailed, case-specific analysis of the causal chain linking cesarean section to death.
- There is no consistent pattern of cesarean indications that inherently predict maternal death, necessitating individualized evaluation.
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