Association of a single prior cesarean delivery with adverse birth outcomes at a tertiary referral hospital in southwestern Uganda: A secondary analysis of four observational studies

BACKGROUND: Prior cesarean delivery (CD) is a leading indication for repeat CD and a key driver of rising cesarean rates in Sub-Saharan Africa. Evidence on associations between prior CD and adverse outcomes in low-resource settings remains limited. OBJECTIVE: We examined the association between one prior CD and adverse maternal and perinatal outcomes and examined current delivery mode as a mediator of this association among women delivering at Mbarara Regional Referral Hospital (MRRH), Uganda. METHODS: We conducted a secondary analysis of four prospective studies at MRRH (2014-2024). The exposure was having one prior CD, and outcomes included composite adverse maternal outcomes (postpartum hemorrhage, infection, blood transfusion, prolonged hospital stay, and others) and composite adverse perinatal outcomes (stillbirth, neonatal death, preterm birth, low birthweight, low Apgar score, and neonatal intensive care unit admission). We compared the odds of adverse outcomes for women with one prior CD to those with none using multivariable logistic regression. Causal mediation analysis was used to assess whether current CD mediated the effect of prior CD on adverse maternal outcomes. RESULTS: Of 2222 women with at least one prior delivery, 611 (27.5%) had one prior CD. Women with one prior CD more often delivered by cesarean (73.7% vs. 26.4%) and experienced more adverse maternal outcomes (24.5% vs. 15.4%, P < 0.001), including prolonged hospital stay (21.6% vs. 12.7%, P < 0.001). Prior CD was associated with increased odds of adverse maternal outcomes (adjusted odds ratio [aOR]: 1.99, 95% confidence interval [CI]: 1.54-2.57), with 88.9% of this effect mediated through current delivery mode (indirect odds ratio [OR]: 1.78, 95% CI: 1.41-2.25; direct OR: 1.09, 95% CI: 0.79-1.51, P = 0.586). Adverse perinatal outcomes (19.1%) did not differ by prior CD status (P = 0.28). HIV-positive serostatus (aOR: 1.29), referral (aOR: 1.69), and low antenatal care (ANC) attendance (aOR: 1.66) independently predicted perinatal outcomes. CONCLUSION: While prior CD was associated with higher odds of poor maternal outcomes due to repeat cesarean, HIV-positive serostatus, facility referral, and low ANC attendance (but not prior CD) independently predicted adverse perinatal outcomes. Individualized delivery planning and improving surgical safety for women with prior CD and strengthened antenatal surveillance are critical to reducing maternal and perinatal morbidity at referral facilities in low-resource settings.