Criteria-based audit of caesarean section in a referral hospital in rural Tanzania

OBJECTIVE: WHO uses the Caesarean section (CS) rate to monitor implementation of emergency obstetric care (EmOC). Although CS rates are rising in sub-Saharan Africa, maternal outcome has not improved. We audited indications for CS and related complications among women with severe maternal morbidity and mortality in a referral hospital in rural Tanzania.METHODS: Cross-sectional study was from November 2009 to November 2011. Women with severe maternal morbidity and mortality were identified and those with CS were included in this audit. Audit criteria were developed based on the literature review and (inter)national guidelines. Tanzanian and Dutch doctors reviewed hospital notes. The main outcome measured was prevalence of substandard quality of care leading to unnecessary CS and delay in performing interventions to prevent CS.RESULTS: A total of 216 maternal near misses and 32 pregnancy-related deaths were identified, of which 82 (33.1%) had a CS. Indication for CS was in accordance with audit criteria for 36 of 82 (44.0%) cases without delay. In 20 of 82 (24.4%) cases, the indication was correct; however, there was significant delay in providing standard obstetric care. In 16 of 82 (19.5%) cases, the indication for CS was not in accordance with audit criteria. During office hours, CS was more often correctly indicated than outside office hours (60.0% vs. 36.0%, P < 0.05).DISCUSSION: Caesarean section rate is not an useful indicator to monitor quality of EmOC as a high rate of unnecessary and potentially preventable CS was identified in this audit.