Bibliographic information
GuidelineWHO recommendations on the management of sickle cell disease during pregnancy, childbirth and the interpregnancy period
Year of Publication2025
Issuing InstitutionWorld Health Organization
Recommendation
New
Base decisions about mode of birth for women with sickle-cell disease (SCD) on the presence or absence of medical or obstetric indications for caesarean birth, availability of local resources (including those required by women to make informed decisions), as well as the woman’s views and preferences. In the absence of medical or obstetric indications for caesarean birth, vaginal birth is preferable.
Recommended
Notes and Remarks
Caesarean birth in the general pregnant population
- WHO concludes that caesarean sections are effective in saving maternal and infant lives, but only when they are required for medically indicated reasons (176). Caesarean sections can cause significant and sometimes permanent complications, disability or death, particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery and treat surgical complications (176). Caesarean birth in women with SCD
- The systematic review conducted to inform this guideline found that the effect of caesarean section compared to vaginal birth on maternal death, stillbirth and neonatal death is uncertain (one crosssectional study; 255 women; very low certainty) (44).
- The GDG acknowledged that there is insufficient evidence to support pre-labour caesarean birth in women with SCD. Decision making about mode of birth
- The GDG acknowledged the need to balance the interaction between the pathophysiological mechanisms of SCD and the management of birth (i.e. anaemia and risks associated with haemorrhage; pain, dehydration and risk of precipitating sickle-cell crises).
- Qualitative evidence based on the views of healthy pregnant women (177) (largely from HICs [76%] but including views from women in upper-middle income [13%] and LICs [11%]) suggests that if women have a preference for caesarean birth, the factors underlying this preference include: a strong fear of pain and injuries to the mother and baby during labour and birth (high confidence); and positive views on caesarean birth based on qualities associated with better organization and control of the birth process (high confidence). Trial of labour after caesarean birth
- The GDG did not find any evidence on trial of labour after caesarean (TOLAC) in women with SCD. Consideration of TOLAC in this population will be informed by obstetric indications and availability of local resources.
- The GDG acknowledged the need for clinical judgement and shared decision making, with reference to local protocols, with regard to undertaking TOLAC in women with SCD.