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

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.