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.
| Original language | English |
|---|---|
| Article number | 100437 |
| Pages (from-to) | 1-12 |
| Number of pages | 12 |
| Journal | AJOG Global Reports |
| Volume | 5 |
| Issue number | 1 |
| Early online date | 21 Dec 2024 |
| DOIs | |
| Publication status | Published - Feb 2025 |
Bibliographical note
Publisher Copyright:© 2024 The Authors
Funding
Our findings suggest that CS decisions were often made too soon, possibly based on short-term safety concerns. This is supported by another study from DSM unfolding how defensive CS decisions were driven by fear of unsafe vaginal births and blame [ 51 ]. While short-term outcomes after CS were reassuring, research is needed to unfold the long-term consequences in this urban, low-resource setting with a fertility rate of 3.6 [ 17 ]. Moreover, considering that these study facilities suffer from high and stagnating burdens of perinatal mortality, this defensive, individually-based decision-making on CS neglects the collective need for resources and the costing cascades that strain already scarce resources [ 41 , 52 , 53 , 54 ]. Considering the staff shortages, high rates of CSs inevitably divert attention from other labouring women during vaginal birth, increasing their obstetric risks [ 32 ]. This further emphasizes the need for a collective, structured, and rights-based approach within urban resource-constrained healthcare systems to ensure best possible and timely care for all [ 13 ]. To move beyond the current defensive CS decision-making, healthcare providers at the study sites emphasized the importance of securing continuous support with timely surveillance during vaginal birth and shortening the decision-to-delivery interval for emergency CS. In addition, context-specific clinical guidelines on timely CS decisions, mandatory second opinions, shared decision-making, and training in prolonged labour, TOLAC and assisted vaginal birth are crucial strategies to reduce CS [ 42 , 55 , 56 , 57 , 58 ]. This study was financially supported by the Danida Fellowship Centre provided by Ministry of Foreign Affairs of Denmark (18-08-KU), Aarhus University Research Foundation, Denmark; and Laerdal Global Health (2021-0095; 40662). The foundations had no role in the design of the study, data collection, analysis, interpretation, or the reporting of the findings.The authors extend their sincere appreciation to the management teams of the 5 health facilities for their active engagement and collaboration, as well as to the nurses-in-charge for their ongoing support and enthusiasm in facilitating data access. Moreover, we would like to thank the research assistants, Christopher Msuya and Fredrick Maleko, from Aga Khan University, Tanzania, for their exceptional efforts in data extraction. This study was financially supported by the Danida Fellowship Centre provided by Ministry of Foreign Affairs of Denmark ( 18-08-KU ), Aarhus University Research Foundation, Denmark; and Laerdal Global Health ( 2021-0095 ; 40662 ). The foundations had no role in the design of the study, data collection, analysis, interpretation, or the reporting of the findings.
| Funders | Funder number |
|---|---|
| DSM | |
| Aga Khan University | |
| Aarhus Universitets Forskningsfond | |
| Udenrigsministeriet | 18-08-KU |
| Laerdal Global Health | 40662, 2021-0095 |
Keywords
- fetal distress
- low-income countries
- PartoMa
- sub-Saharan Africa
- sub-standard care
- Tanzania
- trial of labor
- urban disadvantage