‘Why am I in theatre?’: Decision-making in prolonged labour and caesarean sections in Malawi

The conundrum ‘too little, too late’, suggesting that interventions in labour are performed late or not at all due to lack of resources or accessibility, nowadays sometimes becomes ‘too much, too soon’, judging from the global caesarean section pandemic that has been surging in the last decade. A significant increase in caesarean sections is seen in high-, middle- and low-income settings, often without clear medical indication. This increase is partly fuelled by the challenges that health workers encounter when it comes to arriving at appropriate diagnosis and management of prolonged labour. This thesis describes the experiences and challenges regarding the diagnosis of prolonged labour and subsequent clinical decision-making, particularly around caesarean section in St. Luke’s Hospital, Malosa, Malawi. Chapter 2 points out the lack of a universal approach to prolonged labour: a plenitude of synonyms are used internationally to explain a similar phenomenon. Consensus would facilitate research into prolonged labour and appropriate use of caesarean section, and enable comparisons of incidence and management of prolonged labour between settings.When prolonged labour is established, actions need to be undertaken to accelerate the labour progress. Chapter 3 describes the incidence of prolonged first stage of labour in St. Luke’s Hospital, and the use of the various interventions pertaining to its management. Only a small proportion of women who crossed the action line in the first stage received oxytocin to augment labour and of all caesarean sections performed for prolonged labour, the action line was crossed in less than half of these women. Chapter 4 shows that twice as many caesarean sections as vacuum extractions were performed in case of prolonged second stage of labour. These findings suggest that there are important opportunities to extend the use of less invasive interventions before proceeding to caesarean section. It is crucial to identify women in need of caesarean section, and avoid performing unnecessary procedures, considering the risks. Prolonged first or second stage was sometimes diagnosed without being evident from labour tracings, as seen in chapter 5. This chapter describes the role of Dutch physicians Global Health and Tropical Medicine, a unique specialty training in the Netherlands, preparing doctors for work in low- and middle- income settings. Their presence appeared to influence decision-making around caesarean section. Through audit, the percentage of possibly unnecessary caesarean sections could be decreased. A crucial aspect, when it comes to interventions in labour and especially caesarean section, is the informed consent process. This important element of respectful maternity care does often not sufficiently take place, as previous studies have also shown. Chapter 6 shows that with a simple, locally designed intervention, consisting of a simulation training in informed consent, a poster with key points and an informed consent checklist, the process could be improved. Barriers hampering optimal informed consent were identified by involved health workers through a qualitative study (chapter 7): fear of blame and litigation, partial disclosure of risks in order not to scare women, and other barriers to communication played a role. Lastly, this thesis includes a reflection on the performed research projects and a viewpoint on global health research in general, where we find that opportunities are not fairly distributed (chapter 8). Concluding, adequate management of prolonged labour and an optimal informed consent process are fundamental in preventing unnecessary caesarean sections and providing respectful and equitable birth care, which could contribute to the goal of reduced maternal and perinatal morbidity and mortality. Audit, analysis of local data and low-cost, co-created and context- specific interventions can help achieve this goal. Health care workers and researchers must work together, and reflection on one’s role is vital.