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.

Keywords: PartoMa; Tanzania; fetal distress; low-income countries; sub-Saharan Africa; sub-standard care; trial of labor; urban disadvantage.

Figure 1

The facility-based CS rates and the total number of women included in the study. ^aIf unknown status of labor on admission, women were defined to be in labor.

Figure 2

Distribution of indications for CS and an overview of “medically indicated CS”, “nonmedically indicated CS” and “unclear if medically indicated CS”.* Each case may have more than one indication. * If more than one indication for CS, both indications were reviewed. The group “medically indicated CS” includes CSs where at least one indication was considered absolute, for example, placenta praevia. The group “nonmedically indicated CS” includes indications that, according to the criteria, do not require a CS. The group “unclear if medically indicated” includes CSs that could not be assessed. Within each of the commonest indications, “medically indicated CS” is defined as the indication being in accordance with audit criteria (absolute indication). “Nonmedically indicated CS” is defined as the indication not being in accordance with audit criteria, and no other absolute or nonassessable indication is present. “Unclear if medically indicated” is defined as the indication being either nonassessable or not in accordance with audit criteria, yet another absolute or nonassessable indication for CS is present. ** The proportion in “Unclear if medically indicated” that is nonmedically indicated due to another absolute indication: Previous CS 7/134 (5.2%), prolonged labor/CPD 64/290 (22.1%), fetal distress 67/324 (20.7%), hypertensive disorders in pregnancy 29/71 (40.8%), breech 2/9 (22.2%) and other indications 41/187 (22.0%). *** Other absolute indications in "medically indicated CS": Placenta abruptio n=23, placenta praevia n = 23, uterine rupture n = 7, retained twin n = 5, vacuum failure n = 5, previous reconstructive vaginal surgery n = 4, cervical stenosis n = 3, obstetric tumor n = 3, cervical prolapse n = 2, bartholin's edema n = 1, hip dislocation in previous pregnancy n = 1, pelvic injury n = 1, psychosis n = 1, transverse vaginal septum n = 1. Other indications in “nonmedically indicated CS”: Placenta calcification n = 17, premature rupture of membranes n = 14, long interpregnancy interval n = 12, post date n = 10, grand multiparity n = 5, elderly maternal age n = 4 chorionamnioitis n = 3, polyhydramnios n = 3, twins n = 3, precious baby n = 2, intrauterine fetal death n = 2, maternal distress n = 2, below 16 years of age n = 1, endometriosis n = 1. CPD, Cephalopelvic disproportion; CS, Cesarean section.