Unfolding possible non-medically indicated caesarean sections in five
high-volume urban maternity units in Tanzania: A criterion-based
clinical audit (a PartoMa sub-study)
Abstract
Objective: Assess to what extent caesarean section (CS)
indications followed evidence-based, locally co-created guidelines and
identify reasons contributing to non-medically indicated CSs.
Design: Retrospective cross-sectional study. Setting:
Five urban, high-volume maternity units in Dar es Salaam, Tanzania.
Population: Women underwent CS during a three-month period at
each maternity unit, between 1. October 2021 and 31. August 2022.
Exclusion criteria: unavailable records or unknown indication.
Methods: Case files of CS were audited against pre-defined,
localised criteria. Main Outcome Measures: CS rate, indications
and proportion of non-medically indicated CSs. Results: The CS
rate was 31% (2949/9364); 2674/2949 (91%) CSs were included for
analysis. Main indications were previous CS (1133/2674; 42%), prolonged
labour (746/2674; 28%), and fetal distress (554/2674; 21%). Overall,
1061/2674 (40%) did not comply with audit criteria, main reasons being
one previous CS with no trial of labour (526/1061; 50%); reported
prolonged labour without actual slow labour progress (243/1061; 23%);
and fetal distress with normal FHR (120-160 BPM) at time of decision
(225/1061; 21%). Conclusion: Two in five CSs were categorised
as non-medically indicated at time of decision. Particularly, fear of
poor outcomes and delay in accessing emergency surgery may cause
resource-consuming ‘defensive decision-making’ for CS. Investments in
conducive urban maternity units are crucial to ensure safe vaginal
births and to reach a population-based approach to ensure best possible
timely care for all with the limited resources available.
Funding: Danida Fellowship Centre, Denmark (18-08-KU), Aarhus
University Research Foundation and Laerdal Global Health (2021-0095;
40662).