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Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.
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Figure 1

Methodological quality graph: review authors' judgements about each methodological quality item presented as percentages across all included studies.

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.
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Figure 2

Methodological quality summary: review authors' judgements about each methodological quality item for each included study.

Comparison 1 Vaginal preparation versus control, Outcome 1 Post‐cesarean endometritis.
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Analysis 1.1

Comparison 1 Vaginal preparation versus control, Outcome 1 Post‐cesarean endometritis.

Comparison 1 Vaginal preparation versus control, Outcome 2 Postoperative fever.
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Analysis 1.2

Comparison 1 Vaginal preparation versus control, Outcome 2 Postoperative fever.

Comparison 1 Vaginal preparation versus control, Outcome 3 Wound infection.
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Analysis 1.3

Comparison 1 Vaginal preparation versus control, Outcome 3 Wound infection.

Comparison 1 Vaginal preparation versus control, Outcome 4 Any wound complication.
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Analysis 1.4

Comparison 1 Vaginal preparation versus control, Outcome 4 Any wound complication.

Comparison 1 Vaginal preparation versus control, Outcome 5 Composite wound complication or endometritis.
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Analysis 1.5

Comparison 1 Vaginal preparation versus control, Outcome 5 Composite wound complication or endometritis.

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 1 Post‐cesarean endometritis.
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Analysis 2.1

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 1 Post‐cesarean endometritis.

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 2 Postoperative fever.
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Analysis 2.2

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 2 Postoperative fever.

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 3 Wound infection.
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Analysis 2.3

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 3 Wound infection.

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 4 Any wound complication.
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Analysis 2.4

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 4 Any wound complication.

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 5 Composite wound complication or endometritis.
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Analysis 2.5

Comparison 2 Vaginal preparation versus control ‐ stratified by presence of labor, Outcome 5 Composite wound complication or endometritis.

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 1 Post‐cesarean endometritis.
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Analysis 3.1

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 1 Post‐cesarean endometritis.

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 2 Postoperative fever.
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Analysis 3.2

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 2 Postoperative fever.

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 3 Wound infection.
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Analysis 3.3

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 3 Wound infection.

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 4 Any wound complication.
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Analysis 3.4

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 4 Any wound complication.

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 5 Composite wound complication or endometritis.
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Analysis 3.5

Comparison 3 Vaginal preparation versus control ‐ stratified by presence of ruptured membranes, Outcome 5 Composite wound complication or endometritis.

Summary of findings for the main comparison. Vaginal preparation versus control for preventing postoperative infections

Vaginal preparation versus control for preventing postoperative infections

Population: Pregnant women who received a cesarean delivery
Settings: A hospital in Iran, a hospital in Pakistan, hospitals in Turkey, and hospitals in USA
Intervention: Vaginal preparation with povidone‐iodine solution versus control (saline vaginal wash; no vaginal cleansing)

Outcomes

Illustrative comparative risks* (95% CI)

Relative effect
(95% CI)

No of Participants
(studies)

Quality of the evidence
(GRADE)

Comments

Assumed risk

Corresponding risk

Control

Vaginal preparation versus control

Post‐cesarean endometritis

Study population

RR 0.45
(0.25 to 0.81)

2635
(7 studies)

⊕⊕⊝⊝
low1,2

83 per 1000

37 per 1000
(21 to 67)

Moderate

75 per 1000

34 per 1000
(19 to 61)

Postoperative fever

Study population

RR 0.9
(0.74 to 1.1)

2475
(6 studies)

⊕⊕⊕⊝
moderate1

141 per 1000

127 per 1000
(104 to 155)

Moderate

117 per 1000

105 per 1000
(87 to 129)

Wound infection

Study population

RR 0.86
(0.54 to 1.36)

2205
(6 studies)

⊕⊕⊝⊝
low1,3

33 per 1000

29 per 1000
(18 to 45)

Moderate

31 per 1000

27 per 1000
(17 to 42)

*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: Confidence interval; RR: Risk ratio;

GRADE Working Group grades of evidence
High quality: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low quality: We are very uncertain about the estimate.

1 Most studies contributing data had design limitations.
2 Statistical heterogeneity (I2 = 55%).
3 Wide confidence interval crossing the line of no effect.

Figures and Tables -
Summary of findings for the main comparison. Vaginal preparation versus control for preventing postoperative infections
Comparison 1. Vaginal preparation versus control

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Post‐cesarean endometritis Show forest plot

7

2635

Risk Ratio (M‐H, Random, 95% CI)

0.45 [0.25, 0.81]

2 Postoperative fever Show forest plot

6

2475

Risk Ratio (M‐H, Fixed, 95% CI)

0.90 [0.74, 1.10]

3 Wound infection Show forest plot

6

2205

Risk Ratio (M‐H, Fixed, 95% CI)

0.86 [0.54, 1.36]

4 Any wound complication Show forest plot

2

729

Risk Ratio (M‐H, Fixed, 95% CI)

0.63 [0.37, 1.07]

5 Composite wound complication or endometritis Show forest plot

2

499

Risk Ratio (M‐H, Fixed, 95% CI)

0.46 [0.26, 0.82]

Figures and Tables -
Comparison 1. Vaginal preparation versus control
Comparison 2. Vaginal preparation versus control ‐ stratified by presence of labor

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Post‐cesarean endometritis Show forest plot

3

1394

Risk Ratio (M‐H, Fixed, 95% CI)

0.70 [0.48, 1.02]

1.1 Women in labor

3

523

Risk Ratio (M‐H, Fixed, 95% CI)

0.56 [0.34, 0.95]

1.2 Women not in labor

3

871

Risk Ratio (M‐H, Fixed, 95% CI)

0.89 [0.52, 1.54]

2 Postoperative fever Show forest plot

2

965

Risk Ratio (M‐H, Fixed, 95% CI)

0.82 [0.59, 1.13]

2.1 Women in labor

2

307

Risk Ratio (M‐H, Fixed, 95% CI)

0.68 [0.42, 1.08]

2.2 Women not in labor

2

658

Risk Ratio (M‐H, Fixed, 95% CI)

0.96 [0.61, 1.49]

3 Wound infection Show forest plot

2

959

Risk Ratio (M‐H, Fixed, 95% CI)

0.67 [0.34, 1.34]

3.1 Women in labor

2

307

Risk Ratio (M‐H, Fixed, 95% CI)

0.72 [0.24, 2.21]

3.2 Women not in labor

2

652

Risk Ratio (M‐H, Fixed, 95% CI)

0.64 [0.27, 1.56]

4 Any wound complication Show forest plot

2

729

Risk Ratio (M‐H, Fixed, 95% CI)

0.64 [0.38, 1.09]

4.1 Women in labor

2

314

Risk Ratio (M‐H, Fixed, 95% CI)

0.77 [0.36, 1.61]

4.2 Women not in labor

2

415

Risk Ratio (M‐H, Fixed, 95% CI)

0.54 [0.25, 1.16]

5 Composite wound complication or endometritis Show forest plot

2

499

Risk Ratio (M‐H, Fixed, 95% CI)

0.47 [0.27, 0.85]

5.1 Women in labor

2

164

Risk Ratio (M‐H, Fixed, 95% CI)

0.34 [0.13, 0.87]

5.2 Women not in labor

2

335

Risk Ratio (M‐H, Fixed, 95% CI)

0.60 [0.29, 1.26]

Figures and Tables -
Comparison 2. Vaginal preparation versus control ‐ stratified by presence of labor
Comparison 3. Vaginal preparation versus control ‐ stratified by presence of ruptured membranes

Outcome or subgroup title

No. of studies

No. of participants

Statistical method

Effect size

1 Post‐cesarean endometritis Show forest plot

3

1129

Risk Ratio (M‐H, Fixed, 95% CI)

0.45 [0.29, 0.70]

1.1 Women with ruptured membranes

3

272

Risk Ratio (M‐H, Fixed, 95% CI)

0.24 [0.10, 0.55]

1.2 Women with intact membranes

3

857

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.36, 1.06]

2 Postoperative fever Show forest plot

2

969

Risk Ratio (M‐H, Fixed, 95% CI)

0.83 [0.60, 1.14]

2.1 Women with ruptured membranes

2

200

Risk Ratio (M‐H, Fixed, 95% CI)

0.62 [0.34, 1.12]

2.2 Women with intact membranes

2

769

Risk Ratio (M‐H, Fixed, 95% CI)

0.93 [0.63, 1.36]

3 Wound infection Show forest plot

3

1129

Risk Ratio (M‐H, Fixed, 95% CI)

0.87 [0.49, 1.57]

3.1 Women with ruptured membranes

3

272

Risk Ratio (M‐H, Fixed, 95% CI)

1.22 [0.46, 3.20]

3.2 Women with intact membranes

3

857

Risk Ratio (M‐H, Fixed, 95% CI)

0.72 [0.35, 1.52]

4 Any wound complication Show forest plot

1

300

Risk Ratio (M‐H, Fixed, 95% CI)

0.64 [0.28, 1.44]

4.1 Women with ruptured membranes

1

76

Risk Ratio (M‐H, Fixed, 95% CI)

0.53 [0.15, 1.89]

4.2 Women with intact membranes

1

224

Risk Ratio (M‐H, Fixed, 95% CI)

0.73 [0.25, 2.10]

5 Composite wound complication or endometritis Show forest plot

2

500

Risk Ratio (M‐H, Fixed, 95% CI)

0.48 [0.27, 0.85]

5.1 Women with ruptured membranes

2

134

Risk Ratio (M‐H, Fixed, 95% CI)

0.39 [0.13, 1.13]

5.2 Women with intact membranes

2

366

Risk Ratio (M‐H, Fixed, 95% CI)

0.52 [0.26, 1.04]

Figures and Tables -
Comparison 3. Vaginal preparation versus control ‐ stratified by presence of ruptured membranes