To examine factors that may influence maternal and perinatal mortality associated with caesarean section in an African country. A prospective observational study, conducted between January 1998 and June 2000, of 8070 caesarean sections. 25 district and 2 central hospitals in Malawi. Main outcome measures. Association between hospital type, ward or operative care, training of surgical and anaesthesia personnel, preoperative complications, method of anaesthesia, blood loss and anaesthetic technique on maternal and perinatal mortality. Questionnaires were returned for 5236 caesarean sections in district and 2834 in central hospitals. 95% were emergencies, 65% for obstructed labour. Pre-operative haemorrhagic shock was present in 7.6% of women, anaemia in 6.2% and ruptured uterus in 4.1%. Previous caesarean section did not appear to predispose to ruptured uterus. There were 85 maternal deaths (1.05% mortality), 65 of which occurred postoperatively on the wards. Maternal mortality was increased with ruptured uterus (adjusted odds ratio 3.9, 95% CI 2.3-6.5), little anaesthetic training (2.3, 1.3 to 4.1) and blood loss requiring transfusion (19.3, 9-41). In mothers without preoperative haemorrhage spinal anaesthesia was associated with lower maternal mortality than general anaesthesia (0.23, 0.1-0.7). Perinatal mortality was 11.2% overall, and was significantly associated with ruptured uterus, halothane and ketamine anaesthesia. Maternal and perinatal mortality rates among women undergoing caesarean section in Malawi are high. Improving resuscitation in postoperative wards might reduce maternal mortality. Blood loss and pre-operative complications are both strongly associated with mortality. Spinal anaesthesia was associated with good outcome
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