Disclosing possible nonmedically indicated cesarean sections in 5 high-volume urban maternity units in Tanzania: a criterion-based clinical auditAJOG Global Reports at a Glance

Sarah Hansen, BSc. Med; Monica Lauridsen Kujabi, MD, PhD; Rikke Damkjær Maimburg, PhD; Anna Macha, MD; Luzango Maembe, MD; Idrissa Kabanda, MD; Manyanga Hudson, MD; Rukia Juma Msumi, MD; Mtingele Sangalala, MD; Natasha Housseine, MD, PhD; Brenda Sequeira D'mello, MD, PhD; Kidanto Hussein, MD, PhD; Thomas van den Akker, MD, PhD; Dan Wolf Meyrowitsch, PhD; Nanna Maaløe, MD, PhD

AJOG Global Reports (Feb 2025)

Disclosing possible nonmedically indicated cesarean sections in 5 high-volume urban maternity units in Tanzania: a criterion-based clinical auditAJOG Global Reports at a Glance

Sarah Hansen, BSc. Med,
Monica Lauridsen Kujabi, MD, PhD,
Rikke Damkjær Maimburg, PhD,
Anna Macha, MD,
Luzango Maembe, MD,
Idrissa Kabanda, MD,
Manyanga Hudson, MD,
Rukia Juma Msumi, MD,
Mtingele Sangalala, MD,
Natasha Housseine, MD, PhD,
Brenda Sequeira D'mello, MD, PhD,
Kidanto Hussein, MD, PhD,
Thomas van den Akker, MD, PhD,
Dan Wolf Meyrowitsch, PhD,
Nanna Maaløe, MD, PhD

Affiliations

Sarah Hansen, BSc. Med: Department of Clinical Medicine, Occupational Medicine, Aarhus University, Aarhus, Denmark (Hansen and Maimburg)
Monica Lauridsen Kujabi, MD, PhD: Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark (Kujabi, D'mello, Meyrowitsch, and Maaløe); Department of Gynecology and Obstetrics, Aarhus University Hospital, Aarhus, Denmark (Kujabi)
Rikke Damkjær Maimburg, PhD: Department of Clinical Medicine, Occupational Medicine, Aarhus University, Aarhus, Denmark (Hansen and Maimburg); Department of Midwifery, University College of Northern Denmark, Hjoerring, Denmark (Maimburg)
Anna Macha, MD: Medical College East Africa, Aga Khan University, Dar es Salaam, Tanzania (Macha, Housseine)
Luzango Maembe, MD: Department of Gynecology and Obstetrics, Mwanyanamala Regional Referral Hospital, Dar es Salaam, Tanzania (Maembe)
Idrissa Kabanda, MD: Department of Gynecology and Obstetrics, Sinza Regional Hospital, Dar es Salaam, Tanzania (Kabanda)
Manyanga Hudson, MD: Department of Gynecology and Obstetrics, Temeke Regional Referral Hospital, Dar es Salaam, Tanzania (Hudson)
Rukia Juma Msumi, MD: Department of Gynecology and Obstetrics, Rangi Tatu Maternity Hospital, Dar es Salaam, Tanzania (Msumi)
Mtingele Sangalala, MD: Department of Gynecology and Obstetrics, Amana Regional Referral Hospital, Dar es Salaam, Tanzania (Sangalala)
Natasha Housseine, MD, PhD: Medical College East Africa, Aga Khan University, Dar es Salaam, Tanzania (Macha, Housseine)
Brenda Sequeira D'mello, MD, PhD: Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark (Kujabi, D'mello, Meyrowitsch, and Maaløe); Comprehensive Community Based Rehabilitation in Tanzania, Dar es Salaam, Tanzania (D'mello)
Kidanto Hussein, MD, PhD: Medical College East Africa, Aga Khan University, Dar es Salaam, Tanzania (Macha, Housseine)
Thomas van den Akker, MD, PhD: Athena Institute, VU University Amsterdam, Amsterdam, the Netherlands (Akker); Department of Obstetrics and Gynecology, Leiden University Medical Centre, Leiden, the Netherlands (Akker); Corresponding author: Thomas van den Akker.
Dan Wolf Meyrowitsch, PhD: Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark (Kujabi, D'mello, Meyrowitsch, and Maaløe)
Nanna Maaløe, MD, PhD: Global Health Section, Department of Public Health, University of Copenhagen, Copenhagen, Denmark (Kujabi, D'mello, Meyrowitsch, and Maaløe); Department of Gynecology and Obstetrics, Copenhagen University Hospital –Hvidovre Hospital, Copenhagen, Denmark (Maaløe)

Journal volume & issue: Vol. 5, no. 1
p. 100437

Abstract

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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.

Published in AJOG Global Reports

ISSN: 2666-5778 (Online)
Publisher: Elsevier
Country of publisher: United States
LCC subjects: Medicine: Gynecology and obstetrics
Website: https://www.journals.elsevier.com/ajog-global-reports

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