Front. Glob. Women’s Health Frontiers in Global Women’s Health Front. Glob. Women’s Health 2673-5059 Frontiers Media S.A. 10.3389/fgwh.2025.1605049 Global Women's Health Systematic Review Surgical site infections after caesarean section across sub-Sahara Africa: a scoping review of prevalence and associated factors WoodRebekah 1 * † BorodovaAnna 1 † WolterSophie 1 N’GuessanMicheline 2 DialloAmadou Aziz 3 DialloMamadou Kamis 3 HeldtKatharina 4 RochaCarlos 1 NabéIbrahima 3 DianéBamourou 2 CherifMahamoud Sama 3 MüllerSophie Alice 1 Centre for International Health Protection, Robert Koch Institute, Berlin, Germany University Hospital Bouaké, Bouaké, Côte d'Ivoire Faranah Regional Hospital, Faranah, Guinea Methods Development, Research Infrastructure and Information Technology, Robert Koch Institute, Berlin, Germany

Edited by: Bandit Chumworathayi, Khon Kaen University, Thailand

Reviewed by: Andrew Mgaya, Muhimbili National Hospital, Tanzania

Akmal El-Mazny, Cairo University, Egypt

 Correspondence: Rebekah Wood woodr@rki.de

These authors have contributed equally to this work and share first authorship

 01072025 2025 61605049 15042025 12062025 © 2025 Wood, Borodova, Wolter, N’Guessan, Diallo, Diallo, Heldt, Rocha, Nabé, Diané, Cherif and Müller. 2025Wood, Borodova, Wolter, N’Guessan, Diallo, Diallo, Heldt, Rocha, Nabé, Diané, Cherif and Müller

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Surgical site infections are among the most common healthcare associated infections worldwide and pose a significant risk in cesarean section procedures, which are the most frequently performed surgical operations globally. Our scoping review aimed to synthesize available literature from studies conducted in sub-Saharan Africa on the prevalence of post-caesarean surgical site infections, as well as on reported associated factors. In this scoping review we included studies retrieved in OVID from January 2014 to January 15, 2024 without restrictions on the language of publication or publication status focusing on studies from sub-Saharan African countries. The review was registered on the Open Science Framework platform. The reported rates of surgical site infection across the 73 included studies ranged from 2.0%–56.0%. A forest plot showed that the studies were highly heterogeneous, whereby only 11.0% showed a surgical site infection rate above 20.0%. Most surgical site infections surfaced within two-weeks after a caesarean section. The strongest and most frequently cited risk factors were: duration of labour ≥8 h, surgical duration, multiple vaginal examinations, stored water usage, and premature rupture of membrane. The following protective factors were also determined: Pfannenstiel/transversal incisions, caesarean section at term, having health insurance, normal body mass index, <1 h of surgical intervention, <24 h of premature rupture of membrane, low intraoperative blood loss and absorbable sutures. Staphylococcus aureus was the most commonly isolated pathogen among studies with bacteriological reporting. Our scoping review provides first guidance for regions with limited resources for surveillance, such as sub-Saharan Africa, by outlining most common associated factors and a minimum screening period of two weeks. While utilizing minimal resources effectively, this targeted surveillance could capture the majority of cases and thereby enhancing maternal patient safety.

Systematic Review Registration

https://osf.io/qe7bf/

 surgical site infection wound infection caesarean sub-Saharan Africa scoping review # ZMI5-2523GHP029Global Health Protection Program section-at-acceptanceInfectious Diseases in Women Introduction

Surgical site infections (SSIs) in general are a major cause for post-surgical mortality and morbidity (1). With a global incidence between 3.0 and 15.0% (2), SSIs are among the most common healthcare associated infections worldwide (3). In low-resource settings, there are limited surveillance systems and hence scarce data on prevalence and associated factors of SSIs (4), but existing evidence suggests highest prevalence rates up to 30.9% in the African region (4). The most commonly performed operations around the world are caesarean sections (CSs) (5). In the African region, up to 20.0% of CSs result in SSIs leading to increased maternal morbidity and mortality, longer hospital stays and higher treatment costs (3). A recent systematic review and meta analysis on SSIs after CS reports global risk factors related to comorbidities. These reported risk factors were obesity, diabetes, hypertension, prolonged hospital stays, inappropriate timing of antibiotics, and environmental factors such as overcrowded living conditions and improper hygiene (1). In the African region, there is currently no comprehensive review on SSIs and their risk factors following caesarean section. For the African region, up to now there is no review on SSIs and associated risk factors after CS.

Our scoping review aims to synthesize literature on prevalence of SSIs after CS across sub-Saharan Africa (SSA), while elucidating associated risk and protective factors. This summarization of available evidence and hence deeper understanding of associated factors can potentially guide SSA healthcare stakeholders such as hospitals and practitioners in risk assessment and mitigation for increased maternal patient safety.

 Methods

We conducted a scoping review following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis extension for Scoping Reviews (PRISMA-ScR) (6) and the Joanna Briggs Institute (JBI) methodology for scoping reviews (7). We adapted our search strategy for the African continent from the strategy used by Barth and colleagues (8) in conjunction with the definition of SSA from the World Bank (9). The protocol including the search strategy was published on Open Science Framework (OSF) (10). At the time the protocol was uploaded, no similar reviews were registered in either OSF or PROSPERO. We searched the platform OVID for publications between January 2014 and January 15, 2024 without restrictions on the language of publication or publication status. We used Rayyan (11) for deduplication and EndNote X7 (Clarivate Analytics, PA, USA) for screening and study selection (conducted by AB, RW and SM). Screening of titles and abstracts for assessment as well as screening of full text against the inclusion criteria for the review was done in pairs by the research team (AB, RW, SM, SW). Any disagreement arising at each stage of the selection process was resolved through discussion with first and supervisory authors. Studies were considered eligible if they included women who received CSs in health settings in SSA. All types of studies, including clinical trials, cohort or case-control studies were included. In the case of intervention studies, reported sample size and prevalence for the baseline were used in order to show generalisable prevalence rates. Articles in English and French were included.

Data extraction was done in double and independently by the research team (AB, RW, SM, SW) into a structured form in Microsoft Excel. The extracted variables included: author, publication year, title, journal, publication status, study type, study period, City/Country, sample size, sampling strategy, response rate, inclusion criteria, exclusion criteria, age, SSI prevalence, clinical appearance, sample collection, testing strategy, testing rate, type of infection, type of test, test name, factors investigated, factors associated, level of analysis and additional data. A forest plot was used to display results descriptively and given the hetereogeneity of included studies, a meta analysis was not performed.

 Results Selection of studies

The search identified a total of 395 articles; following the removal of duplicates and critical assessment of title and abstracts, 117 potentially relevant articles were identified for full-text screening (Figure 1). Application of the pre-set eligibility criteria resulted in a final inclusion of 73 articles. All included studies were conducted between January 2009 and March 2023.

PRISMA flow diagram.

Flowchart depicting a systematic review process. Identification: 395 records from OVID, 44 records removed as duplicates. Screening: 371 records screened, 254 excluded. Retrieval: 117 reports sought, 2 not retrieved. Eligibility: 115 reports assessed, 42 excluded for various reasons. Inclusion: 73 studies included in the review. Study characteristics

The included studies contain SSI prevalence data on 51,695 women from 20 countries across SSA, with most studies from Ethiopia (17/73), Nigeria (12/73), Rwanda (11/73) and Tanzania (9/73) (Figure 2, Table 1). The most frequently analyzed health settings were university, teaching or tertiary hospitals 37.0% (27/73), followed by referral, district or regional hospitals 32.9% (24/73). No study included private hospitals. The majority of studies included women who underwent CS at the study site regardless of the indication, whereby 5.5% (4/73) focused on emergency and 2.7% (2/73) on elective CSs only (Table 1).

Country distribution of included publications.

Map of Africa highlighting countries with varying shades of blue, representing the number of publications. Darker shades indicate more publications, with Ethiopia and Nigeria showing the highest counts. A legend on the right denotes the range from one to seventeen publications.

Results of included studies.

Reference and Publication year SSI Definition City, country Study Type Sample size (N) SSI prevalence % (n/N) Follow-up (d) Reported Appearance Factors associated as reported (aOR, 95% CI, p-value) Highest level of analysis Bacteriological Reporting Yes/No
Adane, A. et al. (12) CDC Harar, Dire Dawa, Oromia, Somali, Ethiopia Cohort 336 Overall: 7.7% (26/336) 30 8/26 before discharge Rupture of the membrane before CS (aOR 3.75, 95% CI: 1.85–16.6) Multivariate Yes
Emergency: 14.9% (17/114) 18/26 through follow-up and readmission
Elective: 4.1% (9/222)
Alemye, T. et al. (13) CDC Harar, Ethiopia Cross-sectional 1,069 Overall: 12.3% (131/1,069) 30 NR General anesthesia (aOR 2.02, 95% CI: 1.34–3.02), rupture of membrane before CS (aOR 1.91, 95% CI: 1.18–3.09), post-operative hospital stay > 7d (aOR 2.24, 95% CI: 1.61–3.64), blood transfusion (aOR 4.10, 95% CI: 2.61–6.44) Multivariate No
Emergency: 12.9% (105/811)
Elective: 10.1% (26/258)
Ali, O. et al. (14) Clinical Diagnosis Gondar, Ethiopia Cross-sectional 818 Overall: 12.2% (100/818) NR 60/100 (60.0%) after discharge Chorioamnionitis (aOR 6.46, 95% CI: 1.82–22.71, p = 0.01), Diabetes Mellitus (aOR 6.02, 95% CI: 1.69–21.36, p = 0.005, rupture of membrane ≥ 12 h before CS (aOR 2.94, 95% CI: 1.52–5.67, p = 0.001), MSAF (aOR 2.43, 95% CI: 1.23–4.81, p = 0.011), anemia (aOR 3.44, 95% CI: 1.56–7.56, p = 0.002) Multivariate No
Emergency: 14.0% (96/688)
100/100 (100.0%) within 14 days
Elective: 3.1% (4/130)
Alidina, S. et al. (15) NR Lake Zone, Tanzania Case-control Pre-intervention: 1,120 (intervention) 1,113 (control) Pre-intervention: intervention: 6.5% (73/1,120) 30 NR NR NR No
Control: 8.1% (90/1,113)
Overall Pre-intervention:(163/2,233)
Overall pre-intervention: 2,233
No follow-up after discharge
Post-intervention: intervention: 2.3% (23/980)
Post-intervention: 980 (intervention)
Control: 2.6% (11/427)
427 (control)
Aulakh, A. et al. (16) CDC Gambia Case-control 682 Overall: 13.2% (90/682) 30 51/90 (58.0%) after discharge Decision-to-incision time (p = 0.01), fetal status (p = 0.001), postoperative stay (p = 0.001), antibiotic regimen (p = 0.03) Bivariate No
Emergency: 12.3% (70/571)
Elective 9.1% (3/33)
Ayala, D. et al. (17) CDC Nekemte, Ethiopia Cross-sectional 382 Overall: 8.9% (34/382) 30 NR Age > 35 years (aOR 5.03, 95% CI: 1.69–14.95, p = 0.004), pregnancy-induced hypertension (aOR 5.63, 95% CI: 1.88–16.79, p = 0.002), prolonged Labor (>24 h) (aOR 4.12, 95% CI: 1.01–32.19, p = 0.048), general anesthesia (aOR 3.96, 95% CI: 1.02–15.29, p = 0.040), post-operative hemoglobin <11 g/dl (aOR 4.51, 95% CI: 1.84–11.07, p = 0.001) Multivariate No
Emergency: 8.5% (28/328)
Elective: 11.1% (6/54)
Azeze, G. (18) NR Dahir Dar, Ethiopia Cross-sectional 383 7.8% (30/383) 30 22/30 (73.3%) after discharge Rupture of membrane before CS (aOR 13.9, 95% CI: 2.99–64.8, p = 0.002), vertical skin incision (longitudinal abdominal incision) (aOR 4.77, 95% CI: 1.74–13.06, p = 0.001), duration of surgery >30 m (aOR 4.9, 95% CI: 1.8–13.1, p = 0.001), Interrupted skin closure technique (aOR 6.29, 95% CI: 2.07–19.11, p = 0.002) Multivariate No
Bizuayew, H. et al. (19) CDC Gojjam zone, Northwest Ethiopia Cross-sectional 622 12.4% (77/622) 30 NR Residence (rural) (aOR 2.30, 95% CI: 1.29–4.09, p = 0.005), rupture of membrane >12 h (aOR 4.61, 95% CI: 2.34–9.09, p = 0.001), duration of labor >24 h (aOR 3.48, 95% CI: 1.50–8.09, p = 0.004), hypertension (aOR 3.14, 95% CI: 1.29–7.59, p = 0.011), preoperative hematocrit <30% (aOR 3.22, 95% CI: 1.25–8.31, p = 0.016) Multivariate No
Brisibe, S. et al. (20) NR Port Harcourt, South Nigeria Cross-sectional Site 1 Site 1 baseline: 13.17% (54/410), follow up: 10.34% (43/416); Site 2 13.95% (42/301) None NR None Bivariate No
Baseline: 410, Follow up: 416 Site 2: 301
Buambo, J. et al. (21) NR Brazzaville, Congo Cross-sectional 1,063 38.4% (408/1,063) 30 NR Age <25 years (aOR 2.0, 95% CI: 1.01–4.1, p = 0.04), primary education (aOR 4.1, 95% CI: 1.4–11.8, p = 0.09), BMI > 30 kg/m2 (aOR 5.9, 95% CI: 1.2–27.1, p = 0.02), PROM >6 h (aOR 2.2, 95% CI: 1.1–4.1, p = 0.02), tinted amniotic fluid (aOR 3.6, 95% CI: 1.6–7.6, p = 0.001), duration of surgery >45 min (aOR 21.1, 95% CI: 11.3–39.4, p = 0.001), no dressing (aOR 2.5, 95% CI: 1.3–4.5, p = 0.004), antibiotics (aOR 3.9, 95% CI: 2.2–6.8, p = 0.001) Multivariate No
Carshon-Marsh, R. et al. (22) NR Bo, Sierra Leone Cohort 599 Overall: 7.5% (45/599) 30 (after discharge, telephone calls) NR NA NA No
Mergency:7.4% (40/541)
Elective: 8.6% (5/58)
Cherian, T. et al. (23) CDC Kirehe, Rwanda Cross-sectional 525 9.9% (52/525) 10 ± 3, call 30 NR NA Multivariate No
Chu, K. et al. (24) CDC Burundi, DRC, Sierra Leone Cohort 1,276 7.3% (93/1,276) Until discharge Median: 6 days (range 2–17) Age <30 years (aOR 2.1, 95% CI: 1.2–3.6, p = 0.013), program site (Lubutu) (aOR 0.3, 95% CI: 0.1–0.9, p = 0.038), PROM (aOR 2.1, 95% CI: 1.3–3.4, p = 0.002), neonatal death (aOR 2.7, 95% CI: 1.5–5.0, p = 0.001), antenatal hemorrhage (aOR 0.2, 95% CI: 0.05–1.0, p = 0.050) Multivariate No
Dayo-Dada, T. et al. (25) NR Ekiti State, Nigeria Cohort 1,224 Overall: 16.0% (196/1,224) NR NR Age (X²: 97.714, p < 0.000), Occupation (X²: 80.321, p < 0.000), Gravidity (X²: 175.768, p < 0.000), Parity (X²: 571.065, p < 0.000), Type of Cesarean Section (Emergency vs. Elective) (X²: 0.008, p < 0.000), Indication for CS (X²: 246.844, p < 0.000), Previous Scar (X²: 199.09, p < 0.000) Occupation (X²: 80.321, p < 0.000) Bivariate No
Emergency: 16.0% (146/915)
Elective: 16.2% (50/309)
De Nardo, P. et al. (26) CDC Dodoma, Tanzania Cohort 467 Overall: 48.2% (225/467) 30 Median: 8 days Senior doctor (OR 0.64, 95% CI: 0.43–0.97, p < 0.04), Pfannenstiel (incision) (OR 0.30, 95% CI: 0.18–0.5, p < 0.001), continuous intradermic (OR 0.26, 95% CI: 0.15–0.45, p < 0.001) Bivariate, none significant in multivariate Yes
Emergency: 48.7% (207/425)
Elective: 43% (18/42)
Delamou, A. et al. (27) CDC Multiple districts, Guinea Cohort 7,394 Overall: 7.7% (570/7,394) NR NR Year of surgery:2,014 (aOR 0.70, 95% CI: 0.57–0.84, p = 0.001) 2,015 (aOR 0.43, 95% CI: 0.34–0.55, p < 0.001) comorbidities (aOR 1.54, 95% CI: 1.25–1.90, p < 0.001) Multivariate No
2013: 10.0% (331/3,331)
2014: 7.0% (138/1,971)
2015: 5.0% (101/2,020)
Dessu, S. et al. (28) CDC Dire Dawa, Ethiopia Cases: 119 Controls: 357 476 NA Hospital discharge NR Age 20–34 years (aOR 5.4, 95% CI: 2.35–12.7), age >35 years (aOR: 8.9, 95% CI: 1.8–43.9), <4 vaginal examinations (aOR 4.2, 95% CI: 2.16–8.22), history of chorioamnionitis (aOR 5, 95% CI: 1.05–23.9), previous CS (aOR 6.2, 95% CI: 2.72–14.36), antibiotic prophylaxis (aOR 3.2, 95% CI: 1.81–5.62), perioperative haematocrit level <30% (aOR 6.9, 95% CI: 3.45–14.1), rupture of membrane >12 h (aOR 5.4, 95% CI: 1.84–15.87) Multivariate No
Cases: 119
Controls: 357
Di Genarro, F. et al. (29) CDC Freetown, Sierra Leone Case-control 2,323 10.9% (254/2,323) NR Mean 4.4 ± 1.8 days Being single (aOR 1.48, 95% CI: 1.36–1.66), abnormal BMI, low BMI (aOR 1.42, 95% CI: 1.18–1.72), high BMI (aOR 1.85, 95% CI: 1.02–2.68), admitted from home (aOR 2.35, 95% CI: 2.18–2.59), unemployed (aOR 1.74, 95% CI: 1.24–2.21), low education level (aOR 1.68, 95% CI: 1.55–1.84), presenting with PROM (aOR 1.49, 95% CI: 1.18–1.88), long decision–incision time (aOR 2.08, 95% CI: 1.74–2.24), frequent missing post CS antibiotic doses (aOR 2.52, 95% CI: 2.10–2.85), previous CS (aOR 1.27, 95% CI: 1.10–1.52) Multivariate No
Dlamini, L. et al.* (30) CDC Kampala, Uganda Randomized Clinical Trial 432 Overall: 56.5% (244/432) 10 NR NR Bivariate No
Elbur, A. et al. (31) CDC Khartoum, Sudan Cross-sectional 578 8.3% (48/578) 30 NR NR Multivariate No
Eleje, G. et al. (32) NR Ituku Ozalla/Enugu, Nigeria Cross-sectional Overall: 607 Overall: 6.1% (37/607) NR NR None Bivariate No
During COVID-19: 228 During COVID-19: 6.6% (15/228)
Pre-COVID-19: 379 Pre-COVID-19: 8% (22/379)
Ernest, E. et al. (33) CDC Kagera/Mara regions, Tanzania Cross-sectional 279 Baseline 13.9% (19/136) Until discharge NR Implementation of the safe surgery interventions in both health care center (p = 0.006) and hospitals (p < 0.001) Bivariate No
Follow-up 0.7% (1/143)
Fletcher, R. et al. (34) Clinical Diagnosis Kirehe, Rwanda Cohort 530 5.7% (30/530) ±3 (with Thermal Camera) NR NR NR No
Fletcher, R. et al. (35) NR Kirehe, Rwanda Cohort 572 10.8% (62/572) 10 ± 3 NR NR NR No
Gajewski, J. et al. (36) NR Zambia Randomized Control Trial 1,314 1.6% (21/1,314) NR NR None Bivariate No
Gashaw, A. et al.# (37) CDC Hawassa, Ethiopia Cohort 431 All Emergency: 11.8% (51/431) NR <7 days Multiple vaginal examinations >5 (aOR 6.10, 95% CI: 2.15–17.35, p = 0.001), estimated blood loss >500 ml (aOR 3.16, 95% CI: 1.19–8.38, p = 0.021) duration of labor ≥12 h (aOR 4.05, 95% CI: 1.12–13.7, p = 0.001), rupture of membrane ≥12 h (aOR 4.12, 95% CI: 1.50–11.27, p = 0.006) Multivariate No
22/51 (43,1%)
7–14 days
28/51 (54,9%)
>14 days
1/51 (2.0%)
Gelaw, K. et al. (38) Clinical Diagnosis Maichew, Ethiopia Cross-sectional 384 6.8% (26/384) 30 20/26 (76.9%) before discharge Labor >24 h (aOR 3.48, 95% CI: 1.25–9.68), rupture of membrane before CS (aOR 3.68, 95% CI: 1.13–11.96) midline incision compared to Pfannestiel (aOR = 5.73, 95% CI: 2.05–16.00) Multivariate No
6/26 (23.0%) after discharge
Gentilotti, E. et al. (39) CDC Dodoma, Tanzania Cohort Total: 1,040 Overall: 30.8% (320/1,040) 30 NR Overall/pre-intervention: Pfannenstiel incision (OR 0.29, 95% CI: 0.20–0.42, p < 0.001), continuous intradermic/semi-subcutaneous suture (OR 0.32, 95% CI: 0.23–0.46, p < 0.001); Pre-intervention: higher experience of the surgeon (OR 0.64, 95% CI: 0.43–0.97, p = 0.038) Multivariate Yes
Emergency: 31% (299/964)
Pre: 467 Elective: 27.6% (21/76)
Pre-Intervention: 48.2% (225/467)
Post: 573
Post-Intervention: 16.6% (95/573)
Post-intervention: younger age (OR 2.38, 95% CI: 1.38–4.09, p = 0.001), absorbable stiches (OR 0.47, 95% CI: 0.27–0.81, p = 0.006)
multivariate: lack of pre-incision antibiotic prophylaxis (OR 3.59, 95% CI: 1.92–6.70, p < 0.001), skin disinfection with Dettol/Ethanol (OR 2.40, 95% CI: 1.00–5.74, p = 0.050), absorbable suture (OR 0.52, 95% CI: 0.28–0.97, p = 0.040), normal BMI (18,5–24,9) (OR 0.63, 95% CI: 0.40–0.99, p = 0.045)
Gidiri, M./Ziruma, A. (40) NR Partirenyatwa/Harare, Zimbabwe Randomized Control Trial 232 4.7% (11/232) 42 NR None Bivariate No
Hedt-Gauthier, B. et al. (41) Clinical Diagnosis Kirehe District, Rwanda Cohort 569 10.7% (61/569) 10 NR NR NR No
Igwemadu, G. et al. (42) NR Keffi, Nigeria Randomized Control Trial 162 7.0% (11/162) 14 after discharge NR None Bivariate No
Kabore, B. et al. (43) NR Fada N'Gourma/Diapage, Burkina Faso Case-control 198: cases: 99, controls: 99 NR NR NR Hyperthermia upon admittance (aOR 2.37, 95% CI: 1.9–5.3, p = 0.035), caput succedaneum (aOR 7.0, 95% CI: 2.5–16.7, p = 0.001) difficult extraction of the fetus (aOR 3.69, 95% CI: 1.26–6.3, p = 0.02) Multivariate No
Kasanga, M. et al. (44) NR Lusaka, Zambia Cross-sectional 838 6.0% (50/838) NR NR Secondary education (OR 0.38, 95% CI: 0.15–0.95, p < 0.038), emergency CS (OR 6.25, 95% CI: 2.83–13.80, p < 0.001), oral antibiotics post CS (OR 0.22, 95% CI: 0.05–0.96, p < 0.045), performing facility (OR 0.06, 95% CI: 0.02–0.17, p < 0.001), 8–15d IV antibiotic treatment (OR 18.04, 95% CI: 6.61–49.28, p < 0.001), Bivariate No
Kateera, F. et al. (45) NR Kirehe, Rwanda Randomized Control Trial 871 10.9% (95/871) 30 NR None Bivariate No
Ketema, D. et al. (46) CDC Amhara, Ethiopia Cohort 520 Overall: 25.4% (132/520) 30 Median: 8 days Not able to read and write (AHR 1.30, 95% CI: 1.19–2.11), no antenatal care (AHR 2.16, 95% CI: 1.05–4.53), previous CS (AHR 1.21, 95% CI: 1.11–2.31), HIV positive (AHR 1.39, 95% CI: 1.21–2.57), emergency procedure (AHR 1.13, 95% CI: 1.11–2.43), vertical skin incision (AHR 2.60, 95% CI: 1.05–6.44), rupture of membrane (AHR 1.50, 95% CI: 1.31–1.64), multiple vaginal examination (AHR 1.88, 95% CI: 1.71–3.20) Multivariate No
Emergency: 26.3% (111/422)
Elective: 21.4% (21/98)
(IQR 5–13)
Kpagoi, S. et al. (47) WHO protocol for surgical site infection Bo, Sierra Leone Cross-sectional 596 2.5% (15/596) 30 NR NR NR No
Lijaemiro, H. et al. (48) CDC Addis Ababa, Ethiopia Cohort 166 15.1% (25/166) 30 1–10 days (9.4%) One-year increment in age (aOR 1.50, 95% CI: 1.17–1.93, p < 0.001), gestational age (aOR 0.02, 95% CI: 0.00–0.29, p < 0.004), one-minute increment of duration of surgery (aOR 1.12, 95% CI: 1.03–1.20, p < 0.009), ≥5 vaginal examinations (aOR 13.08, 95% CI: 1.02–168.00, p < 0.048), CS at term (aOR 0.02, 95% CI: 0.00–0.29) Multivariate No
11–17 days (15.6%)
25–30 days (1.4%)
Lukabwe, H. et al.* (49) NR Mbarara, Uganda Randomized Control Trial 96 30.2% (29/96) 30 NR Pre-operative baths with Chloroxylenol (adjusted RR 0.1, 95% CI: 0.03–0.33, p < 0.001) Multivariate No
Mezemir, R. et al. (50) CDC Addis Abeba, Ethiopia Cohort 741 11.6% (86/741) 30 Mean: 9 days 2–3 antenatal care visits (aOR 3.11, 95% CI: 1.69–5.75), delayed antenatal booking (aOR 6.99, 95% CI: 2.09–23.32), PROM (aOR: 2.10, 95% CI: 1.0–4.24), multiple vaginal examinations (aOR 4.21, 95% CI: 1.35–6.92), public hospitals (aOR 11.1, 95% CI: 1.48–45.14), hospital stay <7 days (aOR 0.37, 95% CI: 0.15–0.91), transversal incisions (aOR 0.38, 95% CI: 0.15–0.91) Multivariate Yes
(Range 8–10)
Mivumbi, V. et al. (51) NR Kigali, Rwanda Randomized Control Trial 132 3.8% (5/132) 14 All within 14 days (14 days was the study follow-up time) NR NR Yes
Miyoshi, Y. et al. (52)* NR Zimba, Zambia Cohort 266 2.3% (6/266) NR NR None Bivariate No
Mohammed, S. et al. (53) CDC Kano, Nigeria Randomized Control Trial 154 Overall: 8.4% (13/154) 30 Mean: 7.9 ± 3.8 days None Bivariate No
Emergency: 17.0% (8/47)
Elective: 4.7% (5/107) NR
Molla, M. et al. # (54) CDC Debretabor, Ethiopia Cross-sectional 334 8.1% 27/334) 30 Before discharge: 3/27 (11.1%) Pregnancy induced hypertension (aOR 4.75, 95% CI: 1.62–13.92), chorioamnionitis (aOR 4.37, 95% CI: 1.53–12.50), midline skin incision (aOR 5.19, 95% CI: 1.87–14.37), post-operative hemoglobin l < 11 g/dc (aOR 5.28, 95% CI: 1.97–14.18) Multivariate No
Post Discharge: 24/27 (88.9%)
Mothiba, M. et al. † (55) CDC Pretoria, South Africa Randomized Control Trial 207 0 (0/207) 30 NR None Bivariate No
Mpogoro, F. et al. # (56) CDC Mwanza, Tanzania Cohort 345 10.9% (34/312) 30 Median: 7 days Hypertensive disorder (HR 2.9, 95% CI: 1.4–6.4, p < 0.006); contaminated wound (HR 2.5, 95% CI: 1.2–5.1, p < 0.016), multiple vaginal examinations (HR 2.6, 95% CI: 1.3–5.3, p < 0.008), operation done by intern doctor (HR 4.2,95% CI: 1.8–9.5, p < 0.001), severe anemia (HR 3.8, 95% CI: 1.2–12.4, p < 0.028), duration of procedure >1 h (HR 2.3, 95% CI: 1.1–4.8, p < 0.030) Multivariate Yes
(IQR: 6–9)
Mukantwari, J. et al. (57) CDC Kirehe, Rwanda Cohort 671 10.7% (72/671) 30 11 days: 33/671 (4.9%) Having health insurance (aOR 0.06, 95% CI: 0.01–0.58, p < 0.013), higher economic status (aOR 2.88, 95% CI: 1.39–5.97, p < 0.004) Multivariate No
30 days: 39/671 (5.8%)
Ketemaw, N./ Dereje Zeleke, B. (58) CDC Kaffa Zone, Ethiopia Cohort 368 10.3% (38/368) NR NR None Bivariate No
Ngonzi, J. et al. (59) NR Mbarara, Uganda Cohort 678 Pre-intervention: 14.5% (29/200) Only pre-discharge follow-up NR NR Bivariate No
During intervention: 7.4% (17/230)
Post-intervention: 10.5% (26/248)
Ngowa, J. et al. (60) NR Yaoundé, Cameroun Cohort 460 1.7% (8/460) 30 NR NR Bivariate No
Nguhuni, B. et al. (61) CDC Dodoma, Tanzania Cohort 374 12.0% (45/374) 30 Median: 8 days None NR No
(IQR: 7–11)
Njoku, C. et al. (62) CDC Calabar, Nigeria Cohort 600 Overall: 8.5% (51/600) 30 NR Emergency CS (aOR 4.71, 95% CI: 3.19–5.35, p < 0.001), indication for CS (aOR 1.35, 95% CI: 1.00–1.65, p < 0.002), duration of membrane rupture (aOR 0.52, 95% CI: 0.32–0.95, p < 0.002), duration of labor (aOR 0.47, 95% CI: 0.20–0.79, p < 0.001), intra-operative blood loss >1 L (aOR 1.22, 95% CI: 1.17–2.90, p < 0.048), duration of surgery <1 h (aOR 0.03, 95% CI: 0.01–0.07, p < 0.028), post-operative packed cell volume <30% (aOR 2.60, 95% CI: 1.46–4.12, p < 0.002) Multivariate Yes
Emergency: 11.0% (45/410)
Elective: 3.2% (6/190)
Nkurunziza, T. et al. (63) NICE Kirehe, Rwanda Cohort 550 10.9% (60/550) 10 ± 3 All within 10 days (10 days was the study follow-up time) Transport cost >1.1 EUR (aOR 2.42, 95% CI: 1.31–4.49, p < 0.005), housewife (aOR 2.93, 95% CI: 1.08–7.97, p < 0.035), Skin preparation with one antiseptic (aOR 4.42, 95% CI: 1.05–18.57, p < 0.043) Multivariate No
Nkurunziza, T. et al. (64) CDC Kirehe, Rwanda Cohort 787 POD 10 ± 3: 4.2% (30/715) Home visit with telemedicine: 10 ± 3 All within 10 days (10 days was the study follow-up time) NR NR No
POD 11 ± 3: 5.4% (38/707)
Hospital visit: 11 ± 3,
Odada, D. et al. (65) NHSN Nairobi, Kenya Case-control Total: 1,262 Overall: 2.1% (27/1,262) 30 Out of the 27 SSI (4 dropped due to missing information) None Bivariate Yes
Out of 69 study participants: Emergency: 35.3% (12/34)
(69 study participants) 14 days: 13/23 (56.0%)
Elective: 31.4% (11/35)
15–30 days: 10/23 (43.5%)
Ogah, C. et al. (66)* NR Abakaliki, Nigeria Randomized Control trial 302 (152 control, 150 intervention) Overall: 7.3% (22/302) 30 Mean: 4.1 days None Bivariate Yes
Intervention: wound infection: 5.3% (8/150)
Control: wound infection: 9.2% (14/152)
Onuzo, C. et al. (67) CDC Accra, Ghana Cohort 474 Overall: 12.9% (61/474) 30 Before discharge from hospital: 13/61 (21.3%) Being single (aOR 4.81, 95% CI: 1.21–19.17, p < 0.03), alcohol consumption >3l/week (aOR 5.97, 95% CI: 1.32–26.98, p < 0.02), duration of labor ≥ 8 h (aOR 75.67, 95% CI: 6.61–866.24, p < 0.01), emergency CS (aOR 4.66, 95% CI: 1.22–17.75, p < 0.02), stored water used for pre-operative scrub rather than running water (aOR 18.60, 95% CI: 3.55–97.56, p < 0.01), vertical midline skin incision (aOR 12.55, 95% CI: 2.14—73.63, p < 0.05) Multivariate Yes
Emergency: 16.5% (51/309)
Detected in post-discharge follow-up: 48/61 (78.8%)
Elective: 6.1% (10/165)
Median: 7 days
Onyegbule, O. et al. (68) NR Nnewi, Nigeria Cross-sectional 120 Overall: 12.5% (15/120) Follow-up and diagnosis done at day 4, additional follow-up not NR Follow-up and diagnosis done at day 4, additional follow-up not NR For emergency CS: rupture of membrane <24 h (aOR 0.11, 95% CI: 0.03–0.47, p < 0.003), duration of labor <12 h (aOR 0.07, 95% CI: 0.01–0.32, p < 0.001), Pfannenstiel incision (aOR 0.21, 95% CI: 0.05–0.91, p < 0.038) Multivariate No
Emergency: 20.0% (12/60)
Elective: 5.0% (3/60)
Oyeyem, N. et al. † (69) NR Lagos, Nigeria Randomized Control Trial 190 21.6% (41/190) 14 days and 6 weeks NR None Bivariate No
Peter, E./Ali Seif, S. (70) NR Dodoma, Tanzania Cross-sectional 183 20.8% (38/183) 14 NR Poor wound care (aOR 5.95, 95% CI:1.76–20.17, p < 0.004), earth/sand houses (aOR 4.32, 95% CI: 1.11–16.83, p < 0.03) Multivariate Yes
Rabiu, K. et al. (71) NR Lagos, Nigeria Cohort 906 Overall: 19.4% (176/906) Until Discharge NR Preoperative anemia (aOR 1.88, 95% CI: 1.03–3.41, p < 0.040, diabetes mellitus (aOR 7.94, 95% CI: 1.60–39.27, p < 0.011), HIV infection (aOR 6.34, 95% CI: 1.74–23.06, p < 0.005), prolonged operation time (aOR 2.30, 95% CI: 1.19–4.42, p < 0.013), excessive blood loss at surgery (aOR 5.05, 95% CI: 2.18–11.66, p < 0.000), chorioamnionitis (aOR 9.00, 95% CI: 1.37–59.32, p < 0.022) Multivariate No
Emergency: 24.1% (143/594)
Elective: 10.6% (33/312)
Robb, K. et al. (72) screening protocol Kirehe, Rwanda Cross-sectional 173 9.8% (17/173) 30 NR Lack of water (OR 2.6, p < 0.027) Bivariate No
Sawadogo, Y. et al. (73)* Clinical Diagnosis Ouagadougou, Burkina Faso Cross-sectional 1,998 3.5% (70/1,998) NR Mean: 6,7 ± 2.3 days None NA Yes
Scherbaum, M. et al. (74) RKI/CDC Lambaréné, Gabon Cohort 80 6.3% (5/80) Until discharge All detected before discharge NR NR No
Sway, A. et al. (75) CDC Kiambu, Kenya Cohort 600 6.7% (40/600) 30 NR Administration of pre-operative antibiotic prophylaxis (OR 0.41, 95% CI: 0.20–0.82, p < 0.01) Bivariate No
Ugadu, I. et al. (76) CDC Abakaliki, Nigeria Randomized Control Trial 239 4.6% (11/239) 14 NR Preoperative cleansing on maternal infectious morbidity (RR 0.13, 95% CI: 0.05–0.36, p < 0.000) Bivariate No
Velin, L. et al. (77) CDC Kirehe, Rwanda Cohort 795 5.7% (45/795) 11 ± 3 Range: 8—14 days NR NR Yes
Waalewijn, B. et al. (78) NR Sierra Leone Cohort 1,174 3.7% (36/984) NR NR NR Bivariate No
Wae, M. et al. (79) NR Arba Minch, Ethiopia Cohort 416 12.0% (50/416) NR NR NR NR No
Wendmagegn, T. et al. (80) CDC Mekelle, Ethiopia Cohort 206 Overall: 11.7% (24/206) NR NR PROM (aOR 8.82, 95% CI: 21.71–35.82, p < 0.002), prolonged labor (aOR 16.17, 95% CI: 2.85–91.82), p < 0.006), rural setting (aOR 5.67, 95% CI: 1.57–20.48), HIV positive (aOR 6.98, 95% CI: 1.38–35.27, p < 0.019), chorioamnionitis (aOR 16.17, 95% CI: 2.85–91.82, p < 0.002), blood loss <1000 ml (aOR 0.01 95% CI: 0.02–0.57, p < 0.01) Multivariate No
Emergency: 12.4% (24/193)
Elective: 0.0% (0/13)
Westen, E. et al. (81) NR Lindi/ Masasi, Tanzania Randomized Control Trial 181 8.3% (15/181) 30 NR NR NR No
Wodajo, S. et al. (82) CDC Hawassa Town, Ethiopia Cross-sectional 592 11.0% (65/592) NR Before discharge: 64/65 (98.4%) Prolonged labor >24 h (aOR 6.78, 95% CI: 2.54–18.00), PROM < 12 h (aOR 5.83, 95% CI: 2.14–15.89), 1–4 digital vaginal examinations (aOR 2.91, 95% CI: 1.21–6.99), 5 digital examinations (aOR 8.59, 95% CI: 1.74–42.23), duration of surgery >1 h (aOR 12.32, 95% CI: 5.46–27.77), wound contamination class III (aOR 9.61, 95% CI: 1.84–50.06), conducted by junior professionals (GP) (aOR 7.06, 95% CI: 1.62–30.70) MSc students (aOR 8.31, 95% CI:1.79–28.52), postoperative hemoglobin <11 mg/dl (aOR 2.62, 95% CI: 1.21–5.69) Multivariate No
Woodd, S. et al. (83) CDC Dar es Salaam, Tanzania Cohort 146 8.2% (12/146) 7telephone interview NR NR Multivariate No
Zubairu, U. et al. (84) CDC Zaria, Nigeria Randomized Control Trial 170 11.2% (19/170) 14 Mean: 10.2 ± 3.6 days Level of education (tertiary) (aOR 0.24, 95% CI: 0.08–0.75, p < 0.014), parity <4 (aOR 0.23, 95% CI: 0.08–0.67, p < 0.007), no endometritis (aOR 0.10, 95% CI: 0.03–0.29, p < 0.000), no febrile morbidity (aOR 0.12, 95% CI: 0.02–0.72, p < 0.020) Multivariate No
Emergency: 13.9% (14/101)
Elective: 7.2% (5/69)

CDC, center for disease control and prevention; CI, confidence interval; AHR, adjusted hazard ratio; aOR, adjusted odds ratio; BMI, body mass index; CD, caesarean delivery; CS, c-section; GP, general practitioner; HIV, human immunodeficiency virus; HR, hazard ratio; Md, median; IQR, interquartile range; MSAF, meconium-stained amniotic fluid; MSc, master of science; NA, not applicable; NHSN, national healthcare safety work; NICE, national institute for health and care excellence; NR, not reported; PCV, pac,ed cell volume; POD, post-operative day; PROM, premature rupture of membrane; RKI, Robert-Koch-Institute; RR, relative risk; SD, standard deviation; SSI, surgical site infection; WHO, world health organization.

This study only included emergency C-sections.

Studies that had both elective/emergency C-sections included, whereby SSIs only appeared in those who had an emergency C-section.

Studies which only had elective C-sections included.

In terms of study type, 43.8% (32/73) of included studies were cohort, 28.8% (21/73) cross-sectional studies and 19.2% (14/73) randomized control studies and 8.2% (6/73) case control (Table 1).

Regarding the applied SSI definition, the majority of studies (54.5%, 40/74) reported to have used the Center for Disease Control guidelines (85), but only a slim majority of 52.5% (21/40) of these also conducted patient follow-up for the full recommended 30-day period. In total, a 37.0% (27/73) minority of studies reported full tracking of patients up to 30 days regardless of the definition applied (Table 1).

 SSI rate and appearance time

Reported SSI rates among studies ranged from 2.0% (36)–56.0% (30) (Figure 3). The forest plot showed that the studies were highly heterogeneous (I2 = 100.0%, p < 0.001), and only 11.0% (8/73) of studies showed an SSI rate above 20.0% (Table 1). Regarding the indication for CSs, SSI rates for emergency CS ranged between 7.4% (22) and 48.7% (26), whereby SSI after elective CS from 3.1% (14)–43.0% (26).

Forest plot of SSI rates of included publications.

Forest plot showing the effects of various studies by different authors, with effect sizes ranging from 2.00 to 56.00. Black diamonds represent individual study effects, and a blue diamond represents the overall effect. Confidence intervals are shown, and the weight for each study is 1.41%. Due to high heterogeneity (I² = 100%, p < 0.001), the pooled estimate should be interpreted with caution, thus we did not perform a meta-analysis.

Superficial SSIs had rates as high as 100.0% and were described in 32.3% (24/73) of studies followed by 24.7% (18/73) of studies reporting deep SSIs with highest rate of 32%, and 16.4% (12/73) detailing organ SSIs with rates up to 30.9% (Table 2).

SSI classification in included studies.

Publication SSI Classification (superficial/cutaneous/incisional, deep, and organ, other)
Adane, A. et al. (12) Superficial: 19/26 (73.1%)
Deep: 3/26 (11.5%)
Organ: 4/26 (15.38%)
Ali. O. et al. (14) Superficial: 88/100 (88.0%)
Deep: 12/100 (12.0%)
Organ: NA
Aulukah, A. et al. (16) Superficial: 88/89 (98.9%)
Deep: NA
Organ: 1/89 (1.1%)
Azeze, G./Bizuneh, A. (18) Superficial: 23 (76.7%)
Deep: 7 (23.3%)
Organ: NA
Brisibe, S. F. A. et al. (20) Site 1
Superficial: 16/54 (29.6%)
Deep: 25/54 (46.3%)
Organ: 13/54 (24.1%)
Site 2
Superficial: 10/42 (23.8%)
Deep: 19/42 (45.2%)
Organ: 13/42 (31.0%)
Buambo, J. R. G. et al. (21) Superficial: 90/408 (22.0%)
Other: Endometritis 163/408 (40.0%)
Pelviperitonitis: 65/408 (16.0%)
Chu, K. et al. (24) Superficial: 85/93 (91.4%)
Deep: 7/93 (7.5%)
Unknown: 1/93 (1.1%)
De Nardo,P. et al. (26) Superficial: 138/225 (61.4%)
Deep: 69/225 (30.6%)
Organ/spaces: 5/225 (2.3%)
Unknown: 13/225 (5.7%)
Delamou, A. et al. (27) Cutaneous:
2013: 88.0%
2014: 93.0%
2015: 89.0%
Di Genarro, F. et al. (29) Superficial: 90/254 (35.4%)
Deep: 98/254 (38.6%)
Organ/Space: 66/254 (26.0%)
Gashaw A, et al. (37) Superficial: 33/51 (64.7%)
Deep: 15/51 (29.4%)
Organ/space: 3/51 (5.9%)
Gentilotti, E. et al. (39) Pre:
Superficial: 138/225 (61.3%)
Deep/involving organ and/or space: 74/225 (32.9%)
Post:
Superficial: 80/95 (84.2%)
Deep/involving organ and/or spaces: 11/95 (11.6%)
Overall:
Superficial: 218/320 (68.1%)
Deep/Organ: 85/320 (26.6%)
Lijaemiro et al. (48) Superficial: 17/25 (68.0%)
Deep: 8/25 (32.0%)
Mezemir, R. et al. (50) Superficial: 81/86 (94.1%)
Molla, M. et al. (54) Superficial incisional: 7/27 (27.1%)
Mpogoro, F. et al. (56) Superficial: 21/34 (61.8%)
Organ space: 8/34 (23.5%)
Deep: 5/34 (14.7%)
Nguhuni, B. et al. (61) Superficial: 42/45 (93.3%)
Deep: 2/45 (4.4%)
Oragn/space: 1/45 (2.2%)
Nkurunziza, T. et al. (63) Superficial: 45/60 (75.0%)
Odada, D. et al. (65) Superficial: 18/23 (78.3%)
Deep: 5/23 (21.7%)
Onuzo, C. et al. (67) Superficial: 41/61 (67,2%)
Deep incisional: 18/61 (29.5%)
Organ space: 2/61 (3.3%)
Rabiu, K. A.et al. (71) Superficial: 139/176 (79.0%)
Deep: 37/176 (21.0%)
Sway, A. et al. (75) Thika:
Superficial: 11/12 (91.7)
Organ/space: 1/12 (8.3)
Kiambu:
Superficial: 18/28 (64.3%)
Deep: 7/28 (25.0%)
Organ/Space: 3/28 (10.7%)
Unknown: 1/28 (3.6%)
Velin, L. et al. (77) Superficial: 40/45 (88.9%)
Deep: 5/45 (11.1%)
Wodajo, S. et al. (82) Superficial: 46/65 (70.8%)
Deep: 17/65 (26.1%)
Organ: 2/65 (2.3%)

Appearance time of an SSI was reported by 42.5% (31/73) of included studies. A majority 61.3% (19/31) of those studies stated that most SSIs appear during the first two weeks after CS. Additionally, some studies reported SSI appearance time terms of pre/post-discharge (8/31) out of which a 75% majority (6/8) of SSIs appeared during post-discharge (Table 1).

 Associated factors

Associated factors in the development of SSIs were reported in 38.0% (28/73) of the studies (Table 1). Duration of labour ≥8 h presented as the strongest risk factor (aOR 75.6) (67) and was mentioned in 9.6% (7/73) of the included studies (Table 1). Extended surgical duration, mentioned six times as a risk factor, also presented a substantial risk (aOR 21.1) (21) (Table 1).

A high number (greater than five) of vaginal examinations was mentioned multiple times with a risk of up to 13.1 (48), as well as stored water with aOR of 18.6 (48).

Additionally, chorioamnionitis (aOR 16.2) (80), an infection of the amniotic fluid, also significantly elevated the risk of post-caesarean SSI and was mentioned in five of the included studies (Table 1).

Premature rupture of membrane (PROM), was observed in 14 of the included studies (Table 1), making it the most frequent risk factor with reported aOR of up to 13.9 (18). Anaemia (also reported as low-haemoglobin/haematocrit/packed cell volume) throughout the surgical intervention was mentioned nine times (Table 1) with the highest aOR of 6.9 (28). Vertical/midline skin incisions (aOR 12.6) (67) were also notably high-risk factors compared to Pfannenstiel/transversal incisions which were reported as protective factors (aOR 0.21) (68).

The analysis of protective factors for post-CS outcomes identified several key factors, whereby CS at term (aOR 0.02) (48) presented the strongest protective effect against SSIs.

Having health insurance (aOR 0.06) (57) as well as tertiary level of education (aOR 0.24) (84), demonstrated as protective factors. Within the same study, all other associated factors were found to be protective including parity <4 (aOR 0.23) (84). Women with a normal body mass index (18.5–24.9) showed a protective aOR of 0.63 (39).

As opposed to the demonstrated risk factors of prolonged duration of labour, extended surgery duration and PROM, a <12 h duration of labour (aOR 0.07) (68), less than a 1 h surgical intervention (aOR 0.03) (62) and <24 h of membrane rupture (aOR 0.52) (62) were reported as protective factors.

Other surgical factors such as intraoperative blood loss of <1,000 ml (aOR 0.10) (80) and absorbable sutures (aOR 0.52) (39) were strong protective factors. Lastly, hospital stays of less than seven days had a protective aOR of 0.37 (50).

 Bacteriological profiles

Only a minority of studies (17.8%; 13/73) reported bacteriological test results (Table 1). Staphylococcus aureus (S. aureus) was isolated in all thirteen of the studies with detection rates of up to 52.6% (70), and three of these studies also reported Methicillin-resistant S. aureus (MRSA) (26, 39, 67) which in turn was detected in rates of up to 79.0% (26, 39). One study measuring a 79.0% MRSA rate was able to reduce to a rate of only 21.0% following interventive measures (39).

Gram-negative bacteria were also prominent, particularly Escherichia coli which was identified in nine of the studies, and Klebsiella pneumoniae which was mentioned in seven studies, with two other studies also reporting Klebsiella species. Gram-negative bacteria was also reported as being resistant to ampicillin (100.0%), amoxicillin/clavulanate (93.0%), and trimethoprim/sulfamethoxazole (78.5%) (56) and susceptible or resistant to ceftriaxone (92.1%) and cefepime (84.6%) (77).

 Discussion

This scoping review has a wide geographical representation with included data from 20 SSA countries, whereby most studies came from Ethiopia and Nigeria, possibly reflecting these countries as research epicenters in the region.

Our scoping review found a varying rate of SSIs. However, a large majority reported rates equal or below 20%, reflecting the WHO reporting for the African region (3).

CS are the most commonly performed major operation globally (5), thus surveillance of SSI after CS can be a good starting point for SSI surveillance (3). However, full patient follow-up to day 30 was only conducted in a small minority of studies, demonstrating a possible discordance between international guidelines and their feasibility in resource-limited settings. Given that the majority of SSI were diagnosed within the first two weeks after CS, this time frame could potentially be taken into consideration in the pending update to the WHO SSI surveillance protocol for resource-limited settings (3). Additionally, eight studies examined SSI occurrences in relation to discharge timing, with six reporting that SSIs primarily emerged post-discharge. This highlights the need to follow-up discharged patients, especially within the first two weeks after CS.

Given the limited-resource setting in SSA, the introduction of surveillance systems could start by targeted SSI screening of patients with the risk factors identified as most frequent such as PROM, prolonged labor, duration of surgery, anemia and multiple vaginal examinations. In addition to this targeted surveillance, we would recommend considering measures to mitigate certain risk factors, such as, treating anemia, applying hygiene measures during vaginal examinations and ensuring the provision of clean water. Additionally, certain surgical techniques such as Pfannenstiel (horizontal/transversal) incisions and absorbable sutures should be prioritized given their potential to minimize foreign body reaction (86) and decrease the likelihood of SSIs. SSIs can lead to increased hospital stays, costs, morbidities and mortalities, making their prevention and prompt management a priority (87). Incorporating these protective factors into clinical practice can potentially enhance patient recovery and reduce complication rates and hospitalisation duration. Such incorporation should be done in accordance with the WHO global guidelines for SSI prevention which also specify known protective measures (88).

Our scoping review found a considerable lack in the provision of data on bacteriological profiles. This weakness is in line with recent literature, showing that only 1.0% of laboratories in SSA are formally assigned to deliver bacterial testing (36). However, our synthesized data highlights Staphylococcus aureus as the most frequently reported pathogen causing SSI aligning with data from a recent meta-analysis (30). This is an area of concern considering corresponding reported rates of Methicillin-resistant S. aureus. Prevalence of Gram-negative Klebsiella pneumonia and Escherichia coli also emphasizes the burden of enterobacteria in SSI.

Current literature promotes antibiotic stewardship measures such as selecting the proper antibiotic for prophylaxis in accordance with current resistance data, but acknowledges that stewardship recommendations can be difficult to implement in settings like SSA that have limited antibiotic resources and resistance data (89). These findings, therefore, highlight the urgent need for enhanced bacteriological surveillance and antimicrobial resistance monitoring to inform effective SSI management strategies in the SSA region.

Limitations

This scoping review has several limitations. Despite our inclusive approach and the inclusion of all studies conducted in SSA, only 20 out of 48 of SSA countries were represented with highest representation of Ethiopia and Nigeria. We did not limit our search to English articles, nevertheless, we were only able to retrieve two French publications. As such, we reran the OVID search using French terms, but still did not retrieve additional French articles. Our search strategy only included studies published from 2014 onwards, potentially excluding older but relevant data. Due to the lack of available data in included studies, as well as missing correlation between symptom data and SSI, and vague distinction between wound infection symptoms and other issues such as endometritis, we dropped the analysis of SSI symptom data. Lastly, no private hospitals were included in the selected studies, therefore our findings may not be applicable in those settings.

 Conclusion

Findings from this study can aid those who wish to follow the WHO recommendations in using post-caesarean section SSIs as a practical entry point for healthcare associated infection surveillance. However, low reporting on aspects such as full 30-day follow-up and bacteriological testing from included studies suggests difficulty in implementation of some surveillance measures. As most reported SSIs surfaced within the first two-weeks, this time frame can be taken into consideration as a first step in surveillance implementation. Regions such as SSA that have limited-resources for surveillance and treatment can also consider targeted SSI screening of patients with frequent risk factors, and promotion of reported protective measures. Furthermore, bacteriological diagnostic capacity building is greatly needed in the region in order to improve data gaps and antibiotic treatment recommendations. Utilization of these recommendations can ideally contribute towards improved safety for women undergoing CS in SSA.

 Data availability statement

The original contributions presented in the study are included in the article/Supplementary Material, further inquiries can be directed to the corresponding author.

 Author contributions

RW: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. AB: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing. SW: Data curation, Formal analysis, Software, Writing – original draft. MN: Funding acquisition, Writing – review & editing. AD: Funding acquisition, Writing – review & editing. MD: Writing – review & editing. KH: Conceptualization, Investigation, Methodology, Software, Writing – original draft. CR: Conceptualization, Formal analysis, Methodology, Visualization, Writing – original draft, Writing – review & editing. IN: Conceptualization, Funding acquisition, Project administration, Writing – review & editing. BD: Conceptualization, Funding acquisition, Supervision, Writing – review & editing. MC: Funding acquisition, Writing – review & editing. SM: Conceptualization, Data curation, Formal analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review & editing.

 Funding

The author(s) declare that financial support was received for the research and/or publication of this article. This study was funded by the Global Health Protection Program (# ZMI5-2523GHP029) under project PAcCI (Public Health Actions Ivory Coast) and (# ZMI5-2523GHP024) under project PASQUALE (Partnership to Improve Patient Safety and Quality of Care).

 Acknowledgments

We would like to thank Dr. Francisco Pozo Martin for his experienced insight and guidance in the drafting of this review. Additionally, we thank all the past participants of the many studies included in this scoping review.

 Conflict of interest

The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.

 Generative AI statement

The author(s) declare that no Generative AI was used in the creation of this manuscript.

 Publisher's note

All claims expressed in this article are solely those of the authors and do not necessarily represent those of their affiliated organizations, or those of the publisher, the editors and the reviewers. Any product that may be evaluated in this article, or claim that may be made by its manufacturer, is not guaranteed or endorsed by the publisher.

 Abbreviations

aOR, adjusted odds ratio; BMI, body mass index; CDC, center for disease control and prevention; CI, confidence interval; CS, caesarean section; HIV, human immunodeficiency virus; JBI, Joanna Briggs institute; MRSA, methicillin-resistant staphylococcus aureus; OR, pdds ratio; OSF, open science framework; PRISMA-ScR, preferred reporting items for systematic reviews and meta-analysis extension for scoping reviews; SDGs, sustainable development Goals; SSA, sub-saharan Africa; SSI, surgical site infection; WBG, world bank group; WHO, world health organization.

 References Farid MojtahediMSepidarkishMAlmukhtarMEslamiYMohammadianamiriFBehzad MoghadamK Global incidence of surgical site infections following caesarean section: a systematic review and meta-analysis. J Hosp Infect. (2023) 139:82–92. 10.1016/j.jhin.2023.05.01937308061 Zuarez-EastonSZafranNGarmiGSalimR. Postcesarean wound infection: prevalence, impact, prevention, and management challenges. Int J Womens Health. (2017) 9:81–8. 10.2147/IJWH.S9887628255256 WHO. Protocol for Surgical Site Infection Surveillance with a Focus on Settings with Limited Resources. Geneva: World Health Organization (2018). NejadSBAllegranziBSyedSEllisBPittetD. Health-care-associated infection in Africa: a systematic review. Bull World Health Organ. (2011) 89(10):757–65. 10.2471/BLT.11.08817922084514 GialdiniCChamillardMDiazVPasqualeJThangaratinamSAbalosE Evidence-based surgical procedures to optimize caesarean outcomes: an overview of systematic reviews. EClinicalMedicine. (2024) 72:102632. 10.1016/j.eclinm.2024.102632 TriccoACLillieEZarinWO'BrienKKColquhounHLevacD PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. (2018) 169(7):467–73. 10.7326/M18-085030178033 PetersMGodfreyCMcInerneyPSoaresCKhalilHParkerD. Methodology for JBI scoping reviews. In: AromatarisE, editor. The Joanna Briggs Institute Reviewers Manual. Adelaide, SA: Joanna Briggs Institute (2015). p. 3–24. BarthDDMayosiBMJabarAEngelME. Prevalence of group A streptococcal disease in North and Sub-Saharan Africa: a systematic review protocol. BMJ Open. (2015) 5(8):e008646. 10.1136/bmjopen-2015-00864626316653 WBG. Sub-Saharan Africa (2024). Available online at: https://data.worldbank.org/country/sub-saharan-africa (Accessed August 21, 2024). BorodovaAWoodRMüllerS. Surgical Site Infections after Caesarean Section Across sub-Sahara Africa (2024). Available online at: https://osf.io/qe7bf/ (Accessed February 04, 2025). OuzzaniMHammadyHFedorowiczZElmagarmidA. Rayyan—a web and mobile app for systematic reviews. Syst Rev. (2016) 5(1):210. 10.1186/s13643-016-0384-427919275 AdaneAGedefaLEyeberuATesfaTArkewMTsegayeS Predictors of surgical site infection among women following cesarean delivery in Eastern Ethiopia: a prospective cohort study. Ann Med Surg. (2023) 85(4):738–45. 10.1097/MS9.0000000000000411 AlemyeTOljiraLFekaduGMengeshaMM. Post cesarean section surgical site infection and associated factors among women who delivered in public hospitals in Harar city, Eastern Ethiopia: a hospital-based analytic cross-sectional study. PLoS One. (2021) 16(6):e0253194. 10.1371/journal.pone.025319434161361 AliOKassahunDRadeBKAtnafuA. Maternal factors are important predictors for surgical site infection following cesarean section in Northwest Ethiopian. Clin Epidemiol Glob Health. (2022) 13:100936. 10.1016/j.cegh.2021.100936 AlidinaSMenonGStaffaSJAlrejaSBarashDBarringerE Outcomes of a multicomponent safe surgery intervention in Tanzania's Lake Zone: a prospective, longitudinal study. Int J Qual Health Care. (2021) 33(2):mzab087. 10.1093/intqhc/mzab08734057187 AulakhAIdokoPAndersonSTGrahamW. Caesarean section wound infections and antibiotic use: a retrospective case-series in a tertiary referral hospital in the Gambia. Trop Dr. (2018) 48(3):192–9. 10.1177/0049475517739539 AyalaDTolossaTMarkosJYilmaMT. Magnitude and factors associated with surgical site infection among mothers underwent cesarean delivery in Nekemte town public hospitals, western Ethiopia. PLoS One. (2021) 16(4 April 2021):e0250736. 10.1371/journal.pone.025073633905428 AzezeGGBizunehAD. Surgical site infection and its associated factors following cesarean section in Ethiopia: a cross-sectional study. BMC Res Notes. (2019) 12(1):288. 10.1186/s13104-019-4325-x31133045 BizuayewHAbebeHMulluGBewuketLTsegaDAlemyeT. Post-cesarean section surgical site infection and associated factors in East Gojjam zone primary hospitals, Amhara region, North West Ethiopia, 2020. PLoS One. (2021) 16(12 December):e0261951. 10.1371/journal.pone.026195134972176 BrisibeSFAOrdiniohaBGbeneololPK. The effect of hospital infection control policy on the prevalence of surgical site infection in a tertiary hospital in South-South Nigeria. Niger Med J. (2015) 56(3):194–8. 10.4103/0300-1652.16039326229228 BuamboJREouaniEMPotokouéNSLandouDJItouaCMokokoJC Determinants associated with post-cesarean operating site infections from January 01, 2013 to June 30, 2019 at the Brazzaville university hospital center. East Afr Med J. (2019) 96(1):2296–301. Available at: https://www.ajol.info/index.php/eamj/article/view/194049 Carshon-MarshRSquireJSKamaraKNSargsyanADelamouACamaraBS Incidence of surgical site infection and use of antibiotics among patients who underwent caesarean section and herniorrhaphy at a regional referral hospital, Sierra Leone. Int J Environ Res Public Health. (2022) 19(7):4048. 10.3390/ijerph1907404835409731 CherianTHedt-GauthierBNkurunzizaTSondermanKGruendlMANihiwacuE Diagnosing post-cesarean surgical site infections in rural Rwanda: development, validation, and field testing of a screening algorithm for use by community health workers. Surg Infect (Larchmt). (2020) 21(7):613–20. 10.1089/sur.2020.06232423365 ChuKMaineRTrellesM. Cesarean section surgical site infections in sub-Saharan Africa: a multi-country study from medecins sans frontieres. World J Surg. (2015) 39(2):350–5. 10.1007/s00268-014-2840-425358418 Dayo-DadaTOOjoAAAkporOA. Prevalence of surgical site infection among caesarean section patients in a teaching hospital in Ekiti State, Nigeria: an eight-year review. Sci Afr. (2022) 16:e01216. 10.1016/j.sciaf.2022.e01216 De NardoPGentilottiENguhuniBVairoFChaulaZNicastriE Post-caesarean section surgical site infections at a Tanzanian tertiary hospital: a prospective observational study. J Hosp Infect. (2016) 93(4):355–9. 10.1016/j.jhin.2016.02.02127125664 DelamouACamaraBSSidibéSCamaraADioubatéNEl AyadiAM Trends of and factors associated with cesarean section related surgical site infections in Guinea. J Public Health Afr. (2019) 10(1):1–5. 10.4081/jphia.2019.818 DessuSSamuelSGebremeskelFBasazinATarikuZMarkosM. Determinants of post cesarean section surgical site infection at public hospitals in Dire Dawa administration, Eastern Ethiopia: case control study. PLoS One. (2021) 16(4):e0250174. 10.1371/journal.pone.025017433861783 Di GennaroFMarottaCPisaniLVeroneseNPisaniVLippolisV Maternal caesarean section infection (MACSI) in Sierra Leone: a case-control study. Epidemiol Infect. (2020) 148:e40. 10.1017/S095026882000037032102721 DlaminiLDSekikuboMTumukundeJKojjoCOcenDWabuleA Antibiotic prophylaxis for caesarean section at a Ugandan hospital: a randomised clinical trial evaluating the effect of administration time on the incidence of postoperative infections. BMC Pregnancy Childbirth. (2015) 15(91):1–7. 10.1186/s12884-015-0514-325591791 ElburAIYousifMAEl SayedASAAbdel-RahmanME. Misuse of prophylactic antibiotics and prevalence of postoperative wound infection in obstetrics and gynecology department in a Sudanese hospital. Health. (2014) 6(2):158–64. 10.4236/health.2014.62025 ElejeGUUgwuEOEnebeJTOkoroCCOkpalaBCEzeoraNC Cesarean section rate and outcomes during and before the first wave of COVID-19 pandemic. SAGE Open Med. (2022) 10:20503121221085453. 10.1177/2050312122108545335342633 ErnestECHellarAVaralloJTibyehabwaLBertramMMFitzgeraldL Reducing surgical site infections and mortality among obstetric surgical patients in Tanzania: a pre-evaluation and postevaluation of a multicomponent safe surgery intervention. BMJ Glob Health. (2021) 6(12):e006788. 10.1136/bmjgh-2021-00678834876458 FletcherRRSchneiderGBikorimanaLRukundoGNiyigenaAMirandaE The use of Mobile thermal imaging and deep learning for prediction of surgical site infection. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual International Conference, 2021 (2021). p. 5059–62. FletcherRRSchneiderGHedt-GauthierBNkurunzizaTAlayandeBRivielloR Use of convolutional neural nets and transfer learning for prediction of surgical site infection from color images. Annual International Conference of the IEEE Engineering in Medicine and Biology Society. IEEE Engineering in Medicine and Biology Society. Annual International Conference, 2021 (2021). p. 5047–50. GajewskiJCheeloMBijlmakersLKachimbaJPittalisCBrughaR. The contribution of non-physician clinicians to the provision of surgery in rural Zambia—a randomised controlled trial. Hum Resour Health. (2019) 17(60):1–8. 10.1186/s12960-019-0398-930606232 GashawAFantuSTarekegnM. Factor associated with surgical site infection of women who undergone cesarean section in Hawassa university comprehensive specialized hospital southern Ethiopia, retrospective study design. Int J Surg Open. (2022) 44:100506. 10.1016/j.ijso.2022.100506 GelawKAAwekeAMAstawesegnFHDemissieBWZelekeLB. Surgical site infection and its associated factors following cesarean section: a cross sectional study from a public hospital in Ethiopia. Patient Saf Surg. (2017) 11(1):18. 10.1186/s13037-017-0131-328616079 GentilottiEDe NardoPNguhuniBPisciniADamianCVairoF Implementing a combined infection prevention and control with antimicrobial stewardship joint program to prevent caesarean section surgical site infections and antimicrobial resistance: a Tanzanian tertiary hospital experience. Antimicrob Resist Infect Cont. (2020) 9(1):69. 10.1186/s13756-020-00740-7 GidiriMFZirumaA. A randomized clinical trial evaluating prophylactic single-dose vs prolonged course of antibiotics for caesarean section in a high HIV-prevalence setting. J Obstet Gynaecol. (2014) 34(2):160–4. 10.3109/01443615.2013.83273724456438 Hedt-GauthierBMirandaENkurunzizaTHughesOBoatinAAGajuE Telemedicine for surgical site infection diagnosis in rural Rwanda: concordance and accuracy of image reviews. World J Surg. (2022) 46(9):2094–101. 10.1007/s00268-022-06597-835665833 IgwemaduGTElejeGUEnoEEAkunaeziriUAAfolabiFAAlaoAI Single-dose versus multiple-dose antibiotics prophylaxis for preventing caesarean section postpartum infections: a randomized controlled trial. Women’s Health. (2022) 18:17455057221101071. 10.1177/17455057221101071 KaboréBSoudouemGSeckIMillogoTEvariste YaméogoWMKouandaS. A case-control study of risk factors for surgical site infection after cesarean delivery in eastern Burkina Faso. Int J Gynecol Obstet. (2016) 135(Supplement 1):S107–10. 10.1016/j.ijgo.2016.08.018 KasangaMChilesheMMudendaSMukoshaRKasangaMDakaV Antibiotic prescribing patterns and prevalence of surgical site infections in caesarean section deliveries at two tertiary hospitals in Lusaka, Zambia. Pharmacol Pharm. (2022) 13(8):313–30. 10.4236/pp.2022.138024 KateeraFRivielloRGoodmanANkurunzizaTCherianTBikorimanaL The effect and feasibility of mHealth-supported surgical site infection diagnosis by community health workers after cesarean section in rural Rwanda: randomized controlled trial. JMIR Mhealth Uhealth. (2022) 10(6):e35155. 10.2196/3515535675108 KetemaDBWagnewFAssemieMAFeredeAAlamnehAALeshargieCT Incidence and predictors of surgical site infection following cesarean section in North-west Ethiopia: a prospective cohort study. BMC Infect Dis. (2020) 20(1):902. 10.1186/s12879-020-05640-033256630 KpagoiSSTKKamaraKNCarshon-MarshRDelamouAManziMKamaraRZ Assessing changes in surgical site infections and antibiotic use among caesarean section and herniorrhaphy patients at a regional hospital in Sierra Leone following operational research in 2021. Trop Med Infect Dis. (2023) 8(8):385. 10.3390/tropicalmed808038537624323 LijaemiroHBerhe LemlemSTesfaye DeressaJ. Incidence of surgical site infection and factors associated among cesarean deliveries in selected government hospitals in Addis Ababa, Ethiopia, 2019. Obstet Gynecol Int. (2020) 2020:9714640. 10.1155/2020/971464032148511 LukabweHKajabwanguRMugishaDMayengoHMunyanderuBBalukuA Effectiveness of preoperative bath using chloroxylenol antiseptic soap on the incidence of post emergency cesarean section surgical site infection at Mbarara regional referral hospital, Uganda: a randomized controlled trial. Pan Afr Med J. (2022) 41:92. 10.11604/pamj.2022.41.92.2368735465375 MezemirROlayemiODessieY. Incidence, bacterial profile and predictors of surgical site infection after cesarean section in Ethiopia, a prospective cohort study. Int J Women’s Health. (2023) 15:1547–60. 10.2147/IJWH.S425632 MivumbiVNLittleSERulisaSGreenbergJA. Prophylactic ampicillin versus cefazolin for the prevention of post-cesarean infectious morbidity in Rwanda. Int J Gynecol Obstet. (2014) 124(3):244–7. 10.1016/j.ijgo.2013.09.017 MiyoshiY. Maternal and perinatal outcomes in urgent referral and non-referral cases of emergency cesarean section at a district hospital in zambia: a retrospective observational study. Pan Afr Med J. (2019) 33:324. 10.11604/pamj.2019.33.324.1983231692855 MohammedSA ShuaibuSGayaSRabiuA. The efficacy of two doses versus 7 days’ course of prophylactic antibiotics following cesarean section: an experience from Aminu Kano teaching hospital. Ann Afr Med. (2020) 19(2):103–12. 10.4103/aam.aam_39_1932499466 MollaMTemesgenKSeyoumTMelkamuM. Surgical site infection and associated factors among women underwent cesarean delivery in debretabor general hospital, northwest Ethiopia: hospital based cross sectional study. BMC Pregnancy Childbirth. (2019) 19(1):317. 10.1186/s12884-019-2442-031464598 MothibaMSTshepuwaneTCAdefolaluAOMonokoaneTS. Alexis O-ring wound retractor versus traditional metal retractors for the prevention of postcaesarean surgical site infections. S Afr Fam Pract (2004). (2023) 65(1):a5651. 10.4102/safp.v65i1.5651 MpogoroFJMshanaSEMiramboMMKidenyaBRGumodokaBImirzaliogluC. Incidence and predictors of surgical site infections following caesarean sections at Bugando medical centre, Mwanza, Tanzania. Antimicrob Resist Infect Cont. (2014) 3(1):25. 10.1186/2047-2994-3-25 MukantwariJGateteJdDNiyigenaAAlayandeBTNkurunzizaTMazimpakaC Late and persistent symptoms suggestive of surgical site infections after cesarean section: results from a prospective cohort study in rural Rwanda. Surg Infect (Larchmt). (2023) 24(10):916–23. 10.1089/sur.2023.10038032658 KetemawNDereje ZelekeB. Maternal complications and associated factors among mothers who underwent a cesarean section at Gebretsadik Shewa general hospital: an institution based cross-sectional study. Front Glob Women’s Health. (2023) 4:1091863. 10.3389/fgwh.2023.1091863 NgonziJBebellLMBoatinAAOwaraganiseATiibajukaLFajardoY Impact of an educational intervention on WHO surgical safety checklist and pre-operative antibiotic use at a referral hospital in southwestern Uganda. Int J Qual Health Care. (2021) 33(3):mzab089. 10.1093/intqhc/mzab08934390247 NgowaJDKNgassamAFouogueFTMetogoJMedouAKasiaJM. [Early maternal complications of cesarean section: about 460 cases in two university hospitals in Yaounde, Cameroon]. Complications maternelles precoces de la cesarienne: a propos de 460 cas dans deux hopitaux universitaires de Yaounde, Cameroun. Pan Afr Med J. (2015) 21:265. 10.11604/pamj.2015.21.265.696726600898 NguhuniBDe NardoPGentilottiEChaulaZDamianCMencariniP Reliability and validity of using telephone calls for post-discharge surveillance of surgical site infection following caesarean section at a tertiary hospital in Tanzania. Antimicrob Resist Infect Cont. (2017) 6(1):43. 10.1186/s13756-017-0205-0 NjokuCONjokuAN. Microbiological pattern of surgical site infection following caesarean section at the university of Calabar teaching hospital. Open Access Maced J Med Sci. (2019) 7(9):1430–5. 10.3889/oamjms.2019.28631198449 NkurunzizaTKateeraFSondermanKGruendlMNihiwacuERamadhanB Prevalence and predictors of surgical-site infection after caesarean section at a rural district hospital in Rwanda. Br J Surg. (2019) 106(2):e121–8. 10.1002/bjs.1106030620071 NkurunzizaTWilliamsWKateeraFRivielloRNiyigenaAMirandaE mHealth-community health worker telemedicine intervention for surgical site infection diagnosis: a prospective study among women delivering via caesarean section in rural Rwanda. BMJ Glob Health. (2022) 7(7):e009365. 10.1136/bmjgh-2022-00936535902205 OdadaDShahJMbithiAShahR. Surgical site infections post cesarean section and associated risk factors: a retrospective case-control study at a tertiary hospital in Kenya. Infect Prev Pract. (2024) 6(1):100333. 10.1016/j.infpip.2023.10033338222856 OgahCOAnikweCCAjahLOIkeotuonyeACLawaniOLOkorochukwuBC Preoperative vaginal cleansing with chlorhexidine solution in preventing post-cesarean section infections in a low resource setting: a randomized controlled trial. Acta Obstet Gynecol Scand. (2020) 100(4):694–703. 10.1111/aogs.14060 OnuzoCNSefogahPENuamahMANtumyMOseiM-MNkyekyerK. Surgical site infections following caesarean sections in the largest teaching hospital in Ghana. Infect Prev Pract. (2022) 4(2):100203. 10.1016/j.infpip.2022.10020335265827 OnyegbuleOAkujobiCEzebialuINdukaAAnahaluIOkolieV Determinants of post-caesarean wound infection in Nnewi, Nigeria. Br J Med Med Res. (2015) 5(6):767–74. 10.9734/BJMMR/2015/10297 OyeyemiNOyeneyinLOluwoleAOyeyemiAAfolabiB. Post-operative management in uncomplicated caesarean delivery: a randomised trial of short-stay versus traditional protocol at the Lagos university teaching hospital, Nigeria. Niger Postgrad Med J. (2019) 26(1):31–7. 10.4103/npmj.npmj_166_1830860197 PeterEGAli SeifS. The influence of home environment and wound care practice on surgical site infection among post cesarean section women in Dodoma- Tanzania. Int J Africa Nurs Sci. (2022) 17:100474. 10.1016/j.ijans.2022.100474 RabiuKAkinlusiFAdewunmiAAlausaTDurojaiyeI. Risk factors for postcesarean wound infection in a tertiary hospital in Lagos, Nigeria. Niger Med J. (2020) 61(5):262–8. 10.4103/nmj.NMJ_1_2033487850 RobbKAHabiyakareCKateeraFNkurunzizaTDusabeLKubwimanaM Variability of water, sanitation, and hygiene conditions and the potential infection risk following cesarean delivery in rural Rwanda. J Water Health. (2020) 18(5):741–52. 10.2166/wh.2020.22033095197 SawadogoYAKomboigoEKiemtoreSZamaneHOuedraogoIKainDP Parietal suppurations after cesarean section at the Yalgado OueDraogo university hospital, Burkina Faso: epidemiological clinical, therapeutic and prognostic aspects. Pan Afr Med J. (2019) 32:35. 10.11604/pamj.2019.32.35.1716731143340 ScherbaumMKöstersKMürbethRENgoaUAKremsnerPGLellB Incidence, pathogens and resistance patterns of nosocomial infections at a rural hospital in Gabon. BMC Infect Dis. (2014) 14:1–8. 10.1186/1471-2334-14-12424380631 SwayAWanyoroANthumbaPAikenAChingPMarutaA Prospective cohort study on timing of antimicrobial prophylaxis for post-cesarean surgical site infections. Surg Infect (Larchmt). (2020) 21(6):552–7. 10.1089/sur.2018.22631951506 UgaduIOEgedeJONwigbojiWNIgweCPNwaliASAdebayoJA Pre-operative vs. post-operative vaginal cleansing with povidone-iodine and post-caesarean infectious morbidity: a randomized controlled study. J West Afr Coll Surg. (2022) 12(4):64–74. 10.4103/jwas.jwas_159_2236590785 VelinLUmutesiGRivielloRMuwanguziMBebellLMYankurijeM Surgical site infections and antimicrobial resistance after cesarean section delivery in rural Rwanda. Ann Glob Health. (2021) 87(1):77. 10.5334/aogh.341334430227 WaalewijnBPvan DuinenAKoromaAPRijkenMJElhasseinMBolkanHA. Learning curve characteristics for caesarean section among associate clinicians: a prospective study from Sierra Leone. World J Surg. (2017) 41(12):2998–3005. 10.1007/s00268-017-4202-528887676 MelkamuBWFanuelBNiguseMFelekeH. Magnitude of maternal complications and associated obstetric factors among women who gave birth by cesarean section at arba-minich general hospital, southern Ethiopia: retrospective cohort. J Public Health Epidemiol. (2017) 9(5):133–44. 10.5897/JPHE2016.0898 WendmagegnTAAberaGBTsehayeWTGebresslasieKBTellaBG. Magnitude and determinants of surgical site infecion among women underwent cesarean section in Ayder comprehensive specialized hospital Mekelle City, Tigray region, Northern Ethiopia, 2016. BMC Pregnancy Childbirth. (2018) 18(1):489. 10.1186/s12884-018-2075-830541473 WestenEHKolkPRVan VelzenCLUnkelsRMmuniNSHamisiAD Single-dose compared with multiple day antibiotic prophylaxis for cesarean section in low-resource settings, a randomized controlled, noninferiority trial. Acta Obstet Gynecol Scand. (2015) 94(1):43–9. 10.1111/aogs.1251725263498 WodajoSBelaynehMGebremedhinS. Magnitude and factors associated with post-cesarean surgical site infection at hawassa university teaching and referral hospital, southern Ethiopia: a cross-sectional study. Ethiop J Health Sci. (2017) 27(3):283–90. 10.4314/ejhs.v27i3.1029217927 WooddSLKabanywanyiAMRehmanAMCampbellOMRKagamboAMartiasiW Postnatal infection surveillance by telephone in Dar es Salaam, Tanzania: an observational cohort study. PLoS One. (2021) 16(7):e0254131. 10.1371/journal.pone.025413134197559 ZubairuUDAbdulMABawaUSMaduguNHGhazzaliS. Incidence, timing, and possible risk factors for post-cesarean wound infection among low-risk patients in Zaria, Nigeria: a cross-sectional study. Niger J Basic Clin Sci. (2023) 20(2):177–81. 10.4103/njbcs.njbcs_20_23 CDC. Surgical Site Infection Event (SSI), in National Healthcare Safety Network (2024). MaeharaYShirabeKKohnoeSEmiYOkiEKakejiY Impact of intra-abdominal absorbable sutures on surgical site infection in gastrointestinal and hepato-biliary-pancreatic surgery: results of a multicenter, randomized, prospective, phase II clinical trial. Surg Today. (2017) 47(9):1060–71. 10.1007/s00595-017-1480-328233105 BadiaJMCaseyALPetrosilloNHudsonPMMitchellSACrosbyC. Impact of surgical site infection on healthcare costs and patient outcomes: a systematic review in six European countries. J Hosp Infect. (2017) 96(1):1–15. 10.1016/j.jhin.2017.03.00428410761 WHO. Global Guidelines for the Prevention of Surgical Site Infection. Geneva: World Health Organization (2018). p. 184. Available at: https://www.who.int/publications/i/item/9789241550475 (Accessed March 01, 2025). TadesseBTAshleyEAOngarelloSHavumakiJWijegoonewardenaMGonzálezIJ Antimicrobial resistance in Africa: a systematic review. BMC Infect Dis. (2017) 17:1–17. 10.1186/s12879-017-2713-128049444