Prolonged labour as a driver of the ”caesarean section pandemic”: A
criterion-based audit of caesarean sections in the five highest volume
maternity units in Dar es Salaam, Tanzania
Abstract
Objective: To estimate the proportion of caesarean sections (CS) not
meeting audit criteria for prolonged labour. Design: Cross-sectional.
Setting: Five urban maternity units in Dar es Salaam, Tanzania.
Population: Women giving birth by CS with an indication of prolonged
labour, from October 1 st, 2021 to August 31
st, 2022. Exclusion criteria: referral to the study
sites because of prolonged labour or cervical dilatation >6
cm upon admission; non-cephalic presentation; multiple pregnancy;
intrauterine fetal death; failed induction; previous CS; or other
reasons for CS. Methods: Criterion-based audit of CS case files with
an indication of prolonged labour. Main Outcome Measure : CSs in women
with uncomplicated labour progress. Results: Overall CS rate was 32%
(2949/9364) and 746/1517 (47.9%) of first-time CSs were performed
because of prolonged labour. Out of these, 456 met inclusion criteria
and 243/456 (53.3%) CSs were in uncomplicated labour: 1) women not
being given a trial of labour (78/243, 32.1%); 2) women in first stage
of active labour not crossing the partograph action line (145/243,
59.7%); and 3) women in second stage less than 1 hour (20/243 8.2%).
Conclusion: Almost half of CS in the unscarred uterus were because of
prolonged labour and many did not meet audit criteria for prolonged
labour. Crowded hospitals and inadequate monitoring may have prompted
defensive decision-making. Unconducive labour wards may, therefore,
indirectly drive the CS epidemic while clinical guidelines for CS
decision-making remain scarce.