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).

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.