Disclosing possible nonmedically indicated cesarean sections in 5 high-volume urban maternity units in Tanzania: a criterion-based clinical audit

Abstract

Background

Globally, the cesarean section rate has increased dramatically with many cesarean sections being performed on questionable medical indications. Particularly in urban areas of sub-Saharan Africa, the cesarean section rate is currently increasing rapidly. This potentially undermines the positive momentum of increased facility births and may be a central contributor to a growing "urban disadvantage" in maternal and perinatal health, which is seen in some settings.

Objective

To assess to what extent cesarean section indications follow evidence-based, locally co-created audit criteria in five urban, high-volume maternity units in Dar es Salaam, Tanzania, and identify reasons contributing to nonmedically indicated cesarean sections.

Study Design

This was a retrospective cross-sectional study conducted, from October 1st, 2021 to August 31st, 2022. A criterion-based audit with pre-defined, localized audit criteria was used to examine the clinical case-files of all women who gave birth by cesarean section during 3-month periods at the 5 maternity units. Primary outcomes were the cesarean section rate, indications for cesarean section, and proportion of nonmedically indicated cesarean sections. The PartoMa study is registered in ClinicalTrials.gov (NCT04685668).

Results

Overall, the cesarean section rate was 31.5% (2949/9364), of which 2674/2949 (90.7%) cesarean sections had available data for analysis. Main indications were previous cesarean section (1133/2674; 42.4%), prolonged labor (746/2674; 27.9%), and fetal distress (554/2674; 20.7%). Overall, 1061/2674 (39.7%) did not comply with audit criteria at the time cesarean section was decided. Main reasons were one previous cesarean section with no trial of labor (526/1061; 49.6%); reported prolonged labor without actual slow progress (243/1061; 22.9%); and fetal distress with normal fetal heart rate at time of decision (211/1061; 19.9%).

Conclusion

Two in 5 cesarean sections were categorized as nonmedically indicated at time of decision. Particularly, fear of poor outcomes and delay in accessing emergency surgery may cause resource-consuming "defensive decision-making" for cesarean section. Investments in conducive urban maternity units are crucial to ensure safe vaginal births and to reach a population-based approach that provides best possible timely care for all with the limited resources available.