Assisted vaginal delivery in low and middle income countries: an overview

Objective: To assess the use of assisted vaginal delivery (AVD) in low- and middle-income countries (LMICs), highlighting what level of care procedures were performed and identifying systemic barriers to its use. Design: Cross-sectional health facility assessments. Setting: Up to 40 countries in Latin America, sub-Saharan Africa and Asia. Population: Assessments tended to be national in scope and included all hospitals and samples of midlevel facilities in public and private sectors. Methods: Descriptive secondary data analysis. Main outcome measures: Percentage of facilities where health workers performed AVD in the 3 months prior to the assessment, instrument preference, which health workers performed the procedure, and reasons AVD was not practiced. Results: Fewer than 20% of facilities in Latin America reported performing AVD in the last 3 months. In sub-Saharan Africa, 53% of 1728 hospitals had performed AVD but only 6% of nearly 10 000 health centres had done so. It was not uncommon to find <1% of institutional births delivered by AVD. Vacuum extraction appears preferred over forceps. Lack of equipment and trained health workers were the most frequent reasons for non-performance. Conclusions: The low use of AVD in LMICs is in contrast with many high-income countries, where high caesarean rates are also associated with significant rates of AVD. In many LMICs, rising caesarean rates have not been associated with maintenance of skills and practice of AVD. AVD is underused precisely in countries where pregnant women continue to face hardships accessing emergency obstetric care and where caesarean delivery can be relatively unsafe. Tweetable abstract: Many LMICs exhibit low use of assisted vaginal delivery where access to EmONC continues to be a hardship.