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Abstract
Introduction. Caesarean section (CS) represents the most common and one of the most important operation in obstetrics. Its incidence is on the rise worldwide. Despite the improvement in the technique of CS and anesthesia, adverse maternal and fetal outcomes remain high. We therefore carried out this study to evaluate the places of surgeon and anesthesia in maternal and fetal outcomes of Emergency CS in Yaoundé. Material and methods. We carried out a prospective cohort study from the 1st of November 2016 to the 30th May 2017 in three referral hospitals in Yaoundé. Data collected were entered using Epi info 7.2.0.1 and analyzed with Epi info and SPSS 20.0 using a confidence interval (CI) of 95%. Two-tailed p-values < 0.05 was considered statistically significant. The RR was used to assess the degree of association between studied variables. Results. The mean age was 31.91± 5.15 in the emergency CS group and 26.56 ± 6.08 in the elective CS group. Women who were administered general anesthesia were significantly at least 2 times at risk of hemorrhagic complications, still birth and birth asphyxia than spinal anesthesia (p value = 0.04). Complications occurred more frequently in cases operated by residents than those operated by obstetricians but there was no significantly statistic difference. (p value = 0.16). Conclusion. General anaesthesia is more associated with poor maternal and fetal adverse than spinal anesthesia. Maternal and fetal outcome is not associated to the experience of the surgeon. We therefore recommended to promote the spinal anesthesia technique for CS.
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References
- Benzouina S, Boubkraoui ME, Mrabet M, Chahid N, Kharbach A, El-hassani A, et al. Fetal outcome in emergency versus elective cesarean sections at Souissi Maternity Hospital, Rabat, Morocco. Pan Afr Med J [Internet]. 2016 Apr 15 [cited 2016 Nov 24]; 23(197). Available from: http://www.panafrican-med-journal.com/content/article/23/197/full/#.WDZLTEa-Obs. Consulted on the 8th of May 2017.
- Tapia V, Betran AP, Gonzales GF. Caesarean Section in Peru: Analysis of Trends Using the Robson Classification System. PLOS ONE. 2016 Feb 3; 11(2):e0148138.
- Chu K, Cortier H, Maldonado F, Mashant T, Ford N, Trelles M. Cesarean Section Rates and Indications in Sub-Saharan Africa: A Multi-Country Study from Médecins sans Frontières. PLOS ONE [Internet]. 2012 Sep 4 [cited 2016 Nov 27]; 7(9):e44484. Available from: http://sci-hub.cc/http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0044484. Consulted on 7th of January 2017.
- Souza JP, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med. 2010 Nov 10; 8:71.
- Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, et al. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ [Internet]. 2007 Nov 17 [cited 2016 Nov 27]; 335(7628):1025. Available from:
- http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2078636/. Consulted on 20th of April 2017.
- Nanneli Pallasmaa. Cesarean section – short term maternal complications related to the mode of delivery. Turun yliopiston julkaisuja – annales universitatis turkuensis. Sarja - ser. D osa - tom. 1119 | Medica - Odontologica | Turku 2014. Available from:
- http://www.doria.fi/bitstream/handle/10024/96742/AnnalesD1119Pallasmaa.pdf?sequence=2. Consulted on the 6th of June 2017.
- Deneux-Tharaux Catherine, Carmona Elodie, Bouvier-Colle Marie-Hélene, Bréart Gérard. Postpartum Maternal Mortality and Cesarean Delivery. Obstet Gynecol. 2006 Sep; 108(3):541–8.
- Schutte JM, Steegers E a. P, Schuitemaker NWE, Santema JG, de Boer K, Pel M, et al. Rise in maternal mortality in the Netherlands. BJOG Int J Obstet Gynaecol. 2010 Mar; 117(4):399–406.
- Elvedi-Gasparović V, Klepac-Pulanić T, Peter B. Maternal and fetal outcome in elective versus emergency caesarean section in a developing country. Coll Antropol. 2006 Mar; 30(1):113–8.
- Savage W. The rising caesarean section rate: A loss of obstetric skill? J Obstet Gynaecol [Internet]. 2007 Jan 1 [cited 2016 Nov 27]; 27(4):339–46. Available from: http://dx.doi.org/10.1080/01443610701337916. Consulted on 20th of January 2017.
- Costa ML, Cecatti JG, Souza JP, Milanez HM, Gülmezoglu MA. Using a Caesarean Section Classification System based on characteristics of the population as a way of monitoring obstetric practice. Reprod Health [Internet]. 2010 [cited 2016 Nov 27]; 7:13. Available from: http://dx.doi.org/10.1186/1742-4755-7-13
- Karlström A, Lindgren H, Hildingsson I. Maternal and infant outcome after caesarean section without recorded medical indication: findings from a Swedish case–control study. BJOG Int J Obstet Gynaecol [Internet]. 2013 Mar 1 [cited 2016 Nov 14]; 120(4):479–86. Available from: http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.12129/abstract. Consulted on 15th of Febuary 2017.
- Cavallaro FL, Jenny A Cresswell, Giovanny VA França, Cesar G Victora, Aluísio JD Barros, Carine Ronsman. WHO | Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa. Bull World Health Organ. 2013; 91:914–922D.
- Ugwu E, Obioha K, Okezie O, Ugwu A. A Five-year Survey of Caesarean Delivery at a Nigerian Tertiary Hospital. Ann Med Health Sci Res [Internet]. 2011 [cited 2016 Nov 14]; 1(1):77–83. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3507098/. Consulted on 20th of January 2017.
- Van Roosmalen J, Van Der Does CD. Caesarean birth rates worldwide. A search for determinants. Trop Geogr Med [Internet]. 1994 1995 [cited 2016 Dec 7]; 47(1):19–22. Available from: http://europepmc.org/abstract/med/7747325. Consulted on 20th of January 2017.
- Tebeu PM, Ngassa P, Mboudou E, Kongnyuy E, Binam F, Abena MTO. Neonatal survival following cesarean delivery in northern Cameroon. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2008 Dec; 103(3):259–60.
- Tanyi TJ, Atashili J, Fon PN, Robert T, Paul KN. Caesarean delivery in the Limbé and the Buea regional hospitals, Cameroon: frequency, indications and outcomes. Pan Afr Med J [Internet]. 2016 Jul 13 [cited 2016 Nov 14]; 24(227). Available from: http://www.panafrican-med-journal.com/content/article/24/227/full/#.WCotUcckrIU. Consulted on 6th of May 2017.
- Suwal A, Shrivastava VR, Giri A. Maternal and fetal outcome in elective versus emergency cesarean section. JNMA J Nepal Med Assoc. 2013 Dec; 52(192):563–6.
- Allen VM, O’Connell CM, Baskett TF. Maternal morbidity associated with cesarean delivery without labor compared with induction of labor at term. Obstet Gynecol. 2006 Aug; 108(2):286–94.
- Koroukian SM. Relative risk of postpartum complications in the Ohio Medicaid population: vaginal versus cesarean delivery. Med Care Res Rev MCRR. 2004 Jun; 61(2):203–24.
- Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol. 2004 May; 103(5 Pt 1):907–12.
- Ngowa JDK, Ngassam A, Fouogue JT, Metogo J, Medou A, Kasia JM. Complications maternelles précoces de la césarienne: à propos de 460 cas dans deux hôpitaux universitaires de Yaoundé, Cameroun. Pan Afr Med J [Internet]. 2015 Aug 7 [cited 2016 Nov 14]; 21. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646440/. Consulted on 6th of May 2017.
- Jawad Z, Shazia S, Nadia J, Qudsia A, Shafiq. Maternal and neonatal outcome after spinal versus general anaesthesia for caesarean delivery. Ann Pak Inst Med Sci [Internet]. 2011 [cited 2017 Jun 2]; 7(3):115–8. Available from: http://www.iosrjournals.org/iosr-jdms/papers/Vol13-issue4/Version-6/H013464144.pdf. Consulted on 6th of May 2017.
- Daniel S, Viswanathan M, Simi BN, Nazeema A. Comparison of Fetal Outcomes of Emergency and Elective Caesarean Sections in a Teaching Hospital in Kerala. Acad Med J India [Internet]. 2014 Feb 23 [cited 2016 Nov 14]; 2(1):32–6. Available from:
- http://medicaljournal.in/volume2-issue1-feb-2014-45-original-research-comparison-fetal-outcomes-emergency-elective-caesarean-sections-teaching-hospital-kerala/. Consulted on 6th of May 2017
- Rasheed Faris A, Thikra Najim, Yousif A AL-Raheem.Maternal and fetal outcomes in emergency versus elective two or more previous caesarean deliveries. Available from: http://www.iasj.net/iasj?func=fulltext&aId=1237. Consulted on the 06th June 2017.
- Elvedi-Gasparović V, Klepac-Pulanić T, Peter B. Maternal and fetal outcome in elective versus emergency caesarean section in a developing country. Coll Antropol. 2006 Mar; 30(1):113–8.
- Nkwabong E, Kouam L, Wamba T, Ngassa P, Doh AS, Mve KV, et al. Indication des césariennes à la maternité du CHU de Yaoundé de 2000 A 2004. Clin Mother Child Health [Internet]. 2006 Jan 1 [cited 2017 Jun 2]; 3(1):453–6. Available from:
- https://www.ajol.info/index.php/cmch/article/view/35819. Consulted on 6th of May 2017
- Foumane P, Mve KV, Njofang, Dohbit, Mboudou E. Facteurs de risque et pronostic des césariennes d’urgence à l’hôpital gynéco-obstétrique et pédiatrique de Yaoundé (Cameroun). 2014 [cited 2017 Jun 3]; 24(1):89–93. Available from: http://www.jle.com/fr/revues/mst/e-docs/facteurs_de_risque_et_pronostic_des_cesariennes_durgence_a_lhopital_gyneco_obstetrique_et_pediatrique_de_yaounde_cameroun__301400/article.phtml. Consulted on 6th of May 2017.
- Van Ham MA, Van Dongen PW, Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol. 1997 Jul; 74(1):1–6.
- Diallo FB, Diallo MS, Bangoura S, Diallo AB, Camara Y. Césarienne = facteur de réduction de morbidité et de mortalité fœto-maternelle au centre hospitalier universitaire Ignace Deen de Conakry (Guinée). Med Afr Noire [Internet]. 1998 [cited 2017 Jun 2]; 45(6):359–64. Available from:
- http://cat.inist.fr/?aModele=afficheN&cpsidt=2351268. Consulted on 6th of May 2017.
- Najam R, Sharma R. Maternal and fetal outcomes in elective and emergency caesarean sections at a teaching hospital in North India. A retrospective study. J Adv Res Med Sci Former J Adv Res Biol Sci [Internet]. 2013 [cited 2017 Jun 2]; 5(1):5–9. Available from: http://www.scopemed.org/?mno=34631. Consulted on 6th of May 2017.
- Ghazi A, Karim F, Hussain AM, Ali T, Jabbar S. Maternal morbidity in emergency versus elective caesarean section at a tertiary care hospital. J Ayub Med Coll Abbottabad JAMC. 2012 Mar; 24(1):10–3. 87.
- Shah A, Fawole B, M’imunya JM, Amokrane F, Nafiou I, Wolomby J-J, et al. Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2009 Dec; 107(3):191–7.
- Habib Hussein Ali. Emergency caesarean section turnaround time and its effect on maternal and newborn health outcomes at University of Nairobi teaching hospitals. Available from:
- http://erepository.uonbi.ac.ke/bitstream/handle/11295/13758/Habib_Emergency%20caesarean%20section.pdf?sequence=4. Consulted on 6th of June 2017.
- Martin TC, Bell P, Ogunbiyi O. Comparison of general anaesthesia and spinal anaesthesia for caesarean section in Antigua and Barbuda. West Indian Med J. 2007 Sep; 56 (4):330–3.
- Semagn Mekonen, Eshete A, Kokeb Desta, Yohannes Molla. Maternal and Neonatal outcomes in mothers who undergo caesarean section under General and spinal Anesthesia in Gandhi Memorial Hospital, Addis Ababa - Adv Tech Biol Med [Internet]. 2015 Jan 19 [cited 2017 Jun 2]; 3:119. Available from:
- https://www.esciencecentral.org/journals/maternal-and-neonatal-outcomes-in-mothers-who-undergo-caesarean-section-under-general-and-spinal-anesthesia-in-gandhi-memorial-hospital-addis-ababa-atbm.1000119.pdf. Consulted on the 20th of March 2017.
References
Benzouina S, Boubkraoui ME, Mrabet M, Chahid N, Kharbach A, El-hassani A, et al. Fetal outcome in emergency versus elective cesarean sections at Souissi Maternity Hospital, Rabat, Morocco. Pan Afr Med J [Internet]. 2016 Apr 15 [cited 2016 Nov 24]; 23(197). Available from: http://www.panafrican-med-journal.com/content/article/23/197/full/#.WDZLTEa-Obs. Consulted on the 8th of May 2017.
Tapia V, Betran AP, Gonzales GF. Caesarean Section in Peru: Analysis of Trends Using the Robson Classification System. PLOS ONE. 2016 Feb 3; 11(2):e0148138.
Chu K, Cortier H, Maldonado F, Mashant T, Ford N, Trelles M. Cesarean Section Rates and Indications in Sub-Saharan Africa: A Multi-Country Study from Médecins sans Frontières. PLOS ONE [Internet]. 2012 Sep 4 [cited 2016 Nov 27]; 7(9):e44484. Available from: http://sci-hub.cc/http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0044484. Consulted on 7th of January 2017.
Souza JP, Gülmezoglu A, Lumbiganon P, Laopaiboon M, Carroli G, Fawole B, et al. Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health. BMC Med. 2010 Nov 10; 8:71.
Villar J, Carroli G, Zavaleta N, Donner A, Wojdyla D, Faundes A, et al. Maternal and neonatal individual risks and benefits associated with caesarean delivery: multicentre prospective study. BMJ [Internet]. 2007 Nov 17 [cited 2016 Nov 27]; 335(7628):1025. Available from:
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2078636/. Consulted on 20th of April 2017.
Nanneli Pallasmaa. Cesarean section – short term maternal complications related to the mode of delivery. Turun yliopiston julkaisuja – annales universitatis turkuensis. Sarja - ser. D osa - tom. 1119 | Medica - Odontologica | Turku 2014. Available from:
http://www.doria.fi/bitstream/handle/10024/96742/AnnalesD1119Pallasmaa.pdf?sequence=2. Consulted on the 6th of June 2017.
Deneux-Tharaux Catherine, Carmona Elodie, Bouvier-Colle Marie-Hélene, Bréart Gérard. Postpartum Maternal Mortality and Cesarean Delivery. Obstet Gynecol. 2006 Sep; 108(3):541–8.
Schutte JM, Steegers E a. P, Schuitemaker NWE, Santema JG, de Boer K, Pel M, et al. Rise in maternal mortality in the Netherlands. BJOG Int J Obstet Gynaecol. 2010 Mar; 117(4):399–406.
Elvedi-Gasparović V, Klepac-Pulanić T, Peter B. Maternal and fetal outcome in elective versus emergency caesarean section in a developing country. Coll Antropol. 2006 Mar; 30(1):113–8.
Savage W. The rising caesarean section rate: A loss of obstetric skill? J Obstet Gynaecol [Internet]. 2007 Jan 1 [cited 2016 Nov 27]; 27(4):339–46. Available from: http://dx.doi.org/10.1080/01443610701337916. Consulted on 20th of January 2017.
Costa ML, Cecatti JG, Souza JP, Milanez HM, Gülmezoglu MA. Using a Caesarean Section Classification System based on characteristics of the population as a way of monitoring obstetric practice. Reprod Health [Internet]. 2010 [cited 2016 Nov 27]; 7:13. Available from: http://dx.doi.org/10.1186/1742-4755-7-13
Karlström A, Lindgren H, Hildingsson I. Maternal and infant outcome after caesarean section without recorded medical indication: findings from a Swedish case–control study. BJOG Int J Obstet Gynaecol [Internet]. 2013 Mar 1 [cited 2016 Nov 14]; 120(4):479–86. Available from: http://onlinelibrary.wiley.com/doi/10.1111/1471-0528.12129/abstract. Consulted on 15th of Febuary 2017.
Cavallaro FL, Jenny A Cresswell, Giovanny VA França, Cesar G Victora, Aluísio JD Barros, Carine Ronsman. WHO | Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa. Bull World Health Organ. 2013; 91:914–922D.
Ugwu E, Obioha K, Okezie O, Ugwu A. A Five-year Survey of Caesarean Delivery at a Nigerian Tertiary Hospital. Ann Med Health Sci Res [Internet]. 2011 [cited 2016 Nov 14]; 1(1):77–83. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3507098/. Consulted on 20th of January 2017.
Van Roosmalen J, Van Der Does CD. Caesarean birth rates worldwide. A search for determinants. Trop Geogr Med [Internet]. 1994 1995 [cited 2016 Dec 7]; 47(1):19–22. Available from: http://europepmc.org/abstract/med/7747325. Consulted on 20th of January 2017.
Tebeu PM, Ngassa P, Mboudou E, Kongnyuy E, Binam F, Abena MTO. Neonatal survival following cesarean delivery in northern Cameroon. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2008 Dec; 103(3):259–60.
Tanyi TJ, Atashili J, Fon PN, Robert T, Paul KN. Caesarean delivery in the Limbé and the Buea regional hospitals, Cameroon: frequency, indications and outcomes. Pan Afr Med J [Internet]. 2016 Jul 13 [cited 2016 Nov 14]; 24(227). Available from: http://www.panafrican-med-journal.com/content/article/24/227/full/#.WCotUcckrIU. Consulted on 6th of May 2017.
Suwal A, Shrivastava VR, Giri A. Maternal and fetal outcome in elective versus emergency cesarean section. JNMA J Nepal Med Assoc. 2013 Dec; 52(192):563–6.
Allen VM, O’Connell CM, Baskett TF. Maternal morbidity associated with cesarean delivery without labor compared with induction of labor at term. Obstet Gynecol. 2006 Aug; 108(2):286–94.
Koroukian SM. Relative risk of postpartum complications in the Ohio Medicaid population: vaginal versus cesarean delivery. Med Care Res Rev MCRR. 2004 Jun; 61(2):203–24.
Burrows LJ, Meyn LA, Weber AM. Maternal morbidity associated with vaginal versus cesarean delivery. Obstet Gynecol. 2004 May; 103(5 Pt 1):907–12.
Ngowa JDK, Ngassam A, Fouogue JT, Metogo J, Medou A, Kasia JM. Complications maternelles précoces de la césarienne: à propos de 460 cas dans deux hôpitaux universitaires de Yaoundé, Cameroun. Pan Afr Med J [Internet]. 2015 Aug 7 [cited 2016 Nov 14]; 21. Available from: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4646440/. Consulted on 6th of May 2017.
Jawad Z, Shazia S, Nadia J, Qudsia A, Shafiq. Maternal and neonatal outcome after spinal versus general anaesthesia for caesarean delivery. Ann Pak Inst Med Sci [Internet]. 2011 [cited 2017 Jun 2]; 7(3):115–8. Available from: http://www.iosrjournals.org/iosr-jdms/papers/Vol13-issue4/Version-6/H013464144.pdf. Consulted on 6th of May 2017.
Daniel S, Viswanathan M, Simi BN, Nazeema A. Comparison of Fetal Outcomes of Emergency and Elective Caesarean Sections in a Teaching Hospital in Kerala. Acad Med J India [Internet]. 2014 Feb 23 [cited 2016 Nov 14]; 2(1):32–6. Available from:
http://medicaljournal.in/volume2-issue1-feb-2014-45-original-research-comparison-fetal-outcomes-emergency-elective-caesarean-sections-teaching-hospital-kerala/. Consulted on 6th of May 2017
Rasheed Faris A, Thikra Najim, Yousif A AL-Raheem.Maternal and fetal outcomes in emergency versus elective two or more previous caesarean deliveries. Available from: http://www.iasj.net/iasj?func=fulltext&aId=1237. Consulted on the 06th June 2017.
Elvedi-Gasparović V, Klepac-Pulanić T, Peter B. Maternal and fetal outcome in elective versus emergency caesarean section in a developing country. Coll Antropol. 2006 Mar; 30(1):113–8.
Nkwabong E, Kouam L, Wamba T, Ngassa P, Doh AS, Mve KV, et al. Indication des césariennes à la maternité du CHU de Yaoundé de 2000 A 2004. Clin Mother Child Health [Internet]. 2006 Jan 1 [cited 2017 Jun 2]; 3(1):453–6. Available from:
https://www.ajol.info/index.php/cmch/article/view/35819. Consulted on 6th of May 2017
Foumane P, Mve KV, Njofang, Dohbit, Mboudou E. Facteurs de risque et pronostic des césariennes d’urgence à l’hôpital gynéco-obstétrique et pédiatrique de Yaoundé (Cameroun). 2014 [cited 2017 Jun 3]; 24(1):89–93. Available from: http://www.jle.com/fr/revues/mst/e-docs/facteurs_de_risque_et_pronostic_des_cesariennes_durgence_a_lhopital_gyneco_obstetrique_et_pediatrique_de_yaounde_cameroun__301400/article.phtml. Consulted on 6th of May 2017.
Van Ham MA, Van Dongen PW, Mulder J. Maternal consequences of caesarean section. A retrospective study of intra-operative and postoperative maternal complications of caesarean section during a 10-year period. Eur J Obstet Gynecol Reprod Biol. 1997 Jul; 74(1):1–6.
Diallo FB, Diallo MS, Bangoura S, Diallo AB, Camara Y. Césarienne = facteur de réduction de morbidité et de mortalité fœto-maternelle au centre hospitalier universitaire Ignace Deen de Conakry (Guinée). Med Afr Noire [Internet]. 1998 [cited 2017 Jun 2]; 45(6):359–64. Available from:
http://cat.inist.fr/?aModele=afficheN&cpsidt=2351268. Consulted on 6th of May 2017.
Najam R, Sharma R. Maternal and fetal outcomes in elective and emergency caesarean sections at a teaching hospital in North India. A retrospective study. J Adv Res Med Sci Former J Adv Res Biol Sci [Internet]. 2013 [cited 2017 Jun 2]; 5(1):5–9. Available from: http://www.scopemed.org/?mno=34631. Consulted on 6th of May 2017.
Ghazi A, Karim F, Hussain AM, Ali T, Jabbar S. Maternal morbidity in emergency versus elective caesarean section at a tertiary care hospital. J Ayub Med Coll Abbottabad JAMC. 2012 Mar; 24(1):10–3. 87.
Shah A, Fawole B, M’imunya JM, Amokrane F, Nafiou I, Wolomby J-J, et al. Cesarean delivery outcomes from the WHO global survey on maternal and perinatal health in Africa. Int J Gynaecol Obstet Off Organ Int Fed Gynaecol Obstet. 2009 Dec; 107(3):191–7.
Habib Hussein Ali. Emergency caesarean section turnaround time and its effect on maternal and newborn health outcomes at University of Nairobi teaching hospitals. Available from:
http://erepository.uonbi.ac.ke/bitstream/handle/11295/13758/Habib_Emergency%20caesarean%20section.pdf?sequence=4. Consulted on 6th of June 2017.
Martin TC, Bell P, Ogunbiyi O. Comparison of general anaesthesia and spinal anaesthesia for caesarean section in Antigua and Barbuda. West Indian Med J. 2007 Sep; 56 (4):330–3.
Semagn Mekonen, Eshete A, Kokeb Desta, Yohannes Molla. Maternal and Neonatal outcomes in mothers who undergo caesarean section under General and spinal Anesthesia in Gandhi Memorial Hospital, Addis Ababa - Adv Tech Biol Med [Internet]. 2015 Jan 19 [cited 2017 Jun 2]; 3:119. Available from:
https://www.esciencecentral.org/journals/maternal-and-neonatal-outcomes-in-mothers-who-undergo-caesarean-section-under-general-and-spinal-anesthesia-in-gandhi-memorial-hospital-addis-ababa-atbm.1000119.pdf. Consulted on the 20th of March 2017.