Background
Caesarean section delivery is the most common procedure performed globally, with a projected increase from 21% in 2018 to nearly 29% in 2030 (Betran et al., 2021). And according to the Rwanda Demographic Health Survey (RDHS) of 2019-2020, there has been an increase over the years in the proportion of births delivered by caesarean section (2% in 1992 and 2000, 3% in 2005, 7% in 2010, 13% in 2014-15, and 15% in 2019-20) and this is projected to gradually increase over the coming years.(ASEAN, 2023; NISR, 2019)
It is well known that access to caesarean sections can reduce maternal and neonatal mortality and complications of labour. Even though the World Health Organization advises that caesarean sections be done only when medically necessary, the fact that there is an increasing rate of C-sections should not be ignored (Jinturkar & Sanap, 2019). This increasing incidence of caesarean section in developing world has been accompanied by a rise in surgical site infections and other postoperative complications including abdominal sepsis (Betran et al., 2021). These complications contribute to maternal morbidity and mortality; however, maternal deaths in sub-Saharan Africa remain multifactorial, resulting from a combination of obstetric complications, delays in accessing care and health-system challenges (Onrust et al., 2024).
In many settings, including Rwanda, C-sections are performed to prevent maternal and fetal morbidity or mortality due to complications during childbirth. However, peritonitis after C-section remains a serious clinical concern that can complicate recovery. It can lead to extended hospital stays and even death. Caesarean section remains an important risk factor for developing maternal infection, peritonitis included (Onrust et al., 2024). Peritonitis, is a severe intra-abdominal infection, a rare but serious complication following caesarean section. It is usually a prolonged peritoneal inflammatory response, mostly due to bacteria introduction at the time of surgery. This leads to a cytokine cascade and toxic-mediated endothelial damage, resulting in increased capillary leakage and the onset of severe pelvic-abdominal sepsis (Goris et al., 1985).
Maternal sepsis is the third leading cause of death following haemorrhage and hypertensive disorders at the regional and global scale. It contributes to maternal death at a rate of 11% (Say et al., 2014). Caesarean delivery related peritonitis was identified as the second leading cause of severe maternal morbidity and mortality after Postpartum haemorrhage in Rwanda (Rulisa et al., 2015). However, in Sub- Saharan Africa, sepsis is attributed to 9.7 % of maternal deaths (Litorp et al., 2014). The overall maternal mortality among patients admitted with severe post-partum infections was 5 % in a major tertiary hospital in Rwanda. Severe sepsis from peritonitis was found to be the direct cause of death and the most common diagnosis upon arrival at the tertiary centre (Rwabizi et al., 2016).
Peritonitis being one of the rare severe complication of post C-section, this work focuses on understanding the clinical outcomes of peritonitis in post-C-section patients, as well as identifying key risk factors for maternal morbidity and mortality. All this is critical for improving patient outcomes and optimizing preventive measures.
Methods
This hospital-based retrospective cross-sectional study was conducted at Rwanda Military Teaching Hospital (RMTH). Ethical approval was obtained from the Rwanda Military Teaching Hospital Institutional Review Board (Reference No. 220/RMRTH/COMDT/2025) before commencement of the study. The study involved a review of medical records of women who underwent exploratory laparotomy for post-caesarean section peritonitis over a five-year period, from October 2020 to October 2025. Demographic characteristics, clinical presentation, risk factors, management, and clinical outcomes were analyzed.
The study included all women with a confirmed diagnosis of post-caesarean section peritonitis who were referred from district and provincial hospitals in the Eastern Province of Rwanda. Women with pre-existing intra-abdominal infections (e.g., ruptured appendix or pelvic abscess), as well as those with peritonitis following vaginal delivery or postpartum bowel injury, were excluded.
A consecutive sampling technique was employed to include all eligible patients with complete medical records containing the information required for outcome assessment. Owing to the retrospective nature of the study, no formal sample size calculation was performed. Therefore, the final sample size was determined by the total number of eligible records available during the study period.
Data were extracted retrospectively from patient medical records using a structured data collection tool developed and deployed on KoboToolbox. The electronic tool was designed to capture relevant demographic, obstetric, clinical, management, and outcome variables. KoboToolbox facilitated standardized data entry through built-in validation checks, thereby minimizing data entry errors and missing information. The completed dataset was subsequently exported for cleaning and statistical analysis.
Data were coded, and analyzed using Stata version 19 (StataCorp LLC, College Station, TX, USA). Descriptive statistics were used to summarize patient characteristics, clinical presentation, management, and outcomes. Categorical variables were summarized using frequencies and percentages. Bivariate analysis was performed to assess associations between selected demographic, obstetric, and clinical factors and in-hospital mortality among women with post-caesarean section peritonitis. Crude odds ratios (ORs) with 95% confidence intervals (CIs) were calculated, and a p-value of <0.05 was considered statistically significant.
Results
During the five-year study period (October 2020 to October 2025), a total of 168 women admitted to Rwanda Military Teaching Hospital (RMTH) with a diagnosis of peritonitis secondary to caesarean section were included in the analysis. All patients were referred from peripheral health facilities in the Eastern Province of Rwanda, with the largest proportions referred from Kirehe District Hospital (15.5%), Masaka District Hospital (11.9%), Rwamagana District Hospital (11.3%), and Rwinkwavu District Hospital (11.3%).
The median age of the patients was 25 years. The largest proportion of women were aged 25–34 years (41.7%), followed by those aged 20–24 years (31.6%), while adolescents (<20 years) and women aged ≥35 years accounted for 13.7% and 13.1% of cases, respectively. Most patients were primigravidae (71.9%), whereas 25.8% had 2–5 previous pregnancies and only 2.3% were grand multiparous. The majority (76.2%) had no previous caesarean section, while 23.8% had at least one previous caesarean delivery. Most women (89.9%) had no known medical comorbidity. Emergency caesarean section accounted for 83.9% of cases, with fetal distress (33.3%) and obstructed labour (31.6%) being the most common indications for surgery, followed by repeat caesarean section (19.1%). Spinal anesthesia was used in 95.2% of procedures, whereas general anesthesia was used in 4.8%. Approximately two-thirds of patients (66.1%) presented within the first 10 postoperative days, 32.7% presented between 10 and 30 days, and only 1.2% presented between 30 and 60 days. Preoperative diagnosis of peritonitis was established using both clinical assessment and imaging in 92.3% of patients, while 7.1% were diagnosed using imaging alone and 1.2% based on clinical assessment alone.
Clinical outcomes demonstrated an overall in-hospital mortality rate of 9.6% (16/168), while 90.4% of patients survived to discharge. Sepsis was present in nearly all patients (98.2%), reflecting the severity of illness at presentation. One-quarter of patients (25.0%) required multiple surgical procedures, 23.1% required admission to the intensive care unit (ICU) or high-dependency unit (HDU), 16.7% developed organ failure, 14.9% underwent hysterectomy, and 12.5% sustained organ injury.
Bivariate analysis showed that most demographic and clinical characteristics were not significantly associated with in-hospital mortality (Table 1). Age group, type of caesarean section, type of anesthesia, timing of presentation after surgery, history of rupture of membranes, and intrapartum fever were not significantly associated with mortality (all p > 0.05). Women with a previous caesarean section had significantly higher odds of death than those without a previous caesarean section (OR = 2.88, 95% CI: 1.02–8.10; p = 0.043). Although women with known medical comorbidities had substantially higher odds of mortality (OR = 63.5, 95% CI: 13.6–296.3), this association did not reach statistical significance in the bivariate analysis.
Discussion
The aim of this study was to evaluate the clinical maternal outcomes among women referred and admitted with peritonitis secondary to C-section at RMTH. This study demonstrates that post-caesarean peritonitis remains a severe postoperative complication associated with substantial maternal morbidity and mortality in Rwanda.
Caesarean delivery related peritonitis was identified by S. Rulisa et al as the second leading cause of severe maternal morbidity and mortality after Postpartum haemorrhage in Rwanda with an estimated 9.7% maternal deaths attributed to maternal sepsis (Rulisa et al., 2015). (Litorp et al., 2014) The overall maternal mortality among patients admitted with severe post-partum infections was found to be 5% by Rwabizi et al in a major tertiary hospital in Rwanda (Rwabizi et al., 2016).
Maternal morbidity was considerable. Nearly all patients developed sepsis, one-quarter required repeat surgical intervention, 23.1% required ICU or HDU admission, and 14.9% underwent hysterectomy. The hysterectomy rate, although lower than the 22% reported by Rwabizi et al., reflects the severity of infection and the frequent need for life-saving surgical intervention (Rwabizi et al., 2016). Similarly, the high rate of repeat surgery is consistent with reports by Shan et al where re-laparotomy was associated with severe postoperative complications and adverse outcomes (Rwabizi et al., 2016).
The overall mortality rate was 9.6%, indicating that approximately one in ten women admitted with post-caesarean peritonitis died during hospitalization. This is comparable to previous Rwandan studies by Rwabizi et al and Halfon et al respectively, that reported mortality rates ranging from 5% to 22%.(J. K. Halfon et al., 2016; Rwabizi et al., 2016) This mortality rate is higher than that reported by Sanjay et al in high-income settings, where mortality following post-caesarean intra-abdominal infection is generally below 1% (Gupta & Kaushik, 2006), These findings highlight the persistent burden of severe maternal infection in low-resource settings and underscore the need for early recognition and timely management.
Most women in this study were young, primigravid, and had undergone emergency caesarean section. Similar observations have been reported by Jain et al who found that primary caesarean deliveries were more common among young women of reproductive age (Jain & Patel, 2016). This is strong signal that Peritonitis is overwhelmingly associated with emergency surgery. It also indicates that intrapartum complications dominate the causal pathway to peritonitis more especially if it is a second stage labor C-section.
The predominance of foetal distress (33.3%) and obstructed labour (31.6%) as indications for surgery is also consistent with findings from Sultana et al, suggesting that intrapartum obstetric emergencies account for a large proportion of caesarean deliveries complicated by severe postoperative infection (Sultana et al., 2018).
The majority from our study population (66.1%) presented with symptoms within the first 10 postoperative days, which is broadly comparable to the findings of Halfon et al who reported a median symptom onset of four days following caesarean section (J. Halfon, 2016). Together, these findings suggest that post-caesarean peritonitis typically manifests early in the postoperative period and emphasize the importance of vigilant postoperative surveillance and prompt referral when symptoms develop.
A history of rupture of membranes was documented in 26.1% of patients, and intrapartum fever was reported in 15.7%. Although not statistically associated with death, these findings remain clinically relevant because they are recognized markers of intrauterine infection. Similar observations by Seaward et al demonstrated that prolonged rupture of membranes and infectious intrapartum conditions contribute substantially to postpartum infectious morbidity (Seaward et al., 1997).
Riches et al found a high burden of maternal death following C-section in low-resource settings (Riches et al., 2024) which in comparison with our study findings, a previous caesarean section was found to be associated with increased odds of mortality with statistical significance. (OR = 2.88; 95% CI: 1.02–8.10; p = 0.043). This may be explained by technical complexity during surgery, presence of adhesions, or delayed recognition and management of postoperative complications in repeat procedures.
Multiple surgeries were required in 25% of patients, reflecting severe and persistent intra-abdominal infection. This finding is consistent with the observations of Shan et al, who reported increased adverse outcomes among women undergoing relaparotomy after caesarean section (Shan et al., 2025). Early diagnosis, adequate source control, and timely referral remain essential for improving clinical outcomes.
Overall, the findings of this study reinforce the need for strengthened infection prevention measures during caesarean delivery, improved postoperative monitoring, early recognition of maternal sepsis, timely referral to tertiary centres, and access to multidisciplinary critical care services in order to reduce the burden of post-caesarean peritonitis and its associated mortality.
Conclusion
Peritonitis following C-section at RMTH is associated with substantial morbidity and a high burden of severe complications, with a considerable high mortality rate, nearly 10%. Among the evaluated factors, only a previous history of caesarean section showed a statistically significant association with mortality. Improving prevention strategies, enhancing competencies in emergency obstetric care through clinical training and workforce capacity is essential.
Acknowledgements
We are grateful to the administration and staff of the Rwanda Military Teaching Hospital (RMTH) for the support to run the study especially the department of Obstetrics and Gynaecology. The mentorship provided by ECSACOG trainers is highly appreciated
Funding
No funding received for this study.
Availability of data and materials
Data are available from authors according to the Rwanda Ministry of Health guidelines.
Authors’ contributions
GM conducted the study. EN assisted in data analysis and performed statistical analyses. HG, RM and TR assisted in all aspects of study design and conduct. All authors contributed substantially to manuscript writing and preparation, project conception, design, and evaluation. All authors read and approved the final manuscript.
Competing interests
The authors declare no competing interests
Ethics approval and consent to participate
The RMTH Institutional Review Board Approved the study. (Reference number: 220/RMRTH/COMDT2025)