Disclosing doubtful indications for emergency cesarean sections in rural hospitals in Tanzania: a retrospective criterion-based audit.

Objective. To investigate in depth to what extent indications for emergency cesarean sections followed evidence-based audit criteria for realistic best practice. Design. A quality assurance analysis based on a retrospective criterion-based audit. Setting. Two rural hospitals in Tanzania. Population. From 2009, 400 cesarean section instances were investigated. Of these, 303 were emergency cesarean sections and therefore included. Methods. Documented indications for and management preceding the emergency cesarean sections were compared with the audit criteria. Main outcome measures. Prevalence of suboptimal care. Results. Of the emergency sections, 26% appeared to be decided based on inappropriate indications, and in an additional 38%, the indications were unclear. Prolonged labor was the leading indication; in 36% of these, labor progressed timely and/or the membranes were still intact. In 26%, previous cesarean section was the indication, half of these with one previous section only. Fetal distress was an indication in 14%, but for 84% of these the fetal heart rate was either reassuring or not documented. For nine women, section was decided upon because of intrauterine fetal death; none had a trial of forceps/vacuum extraction or destructive surgery. Conclusion. A considerable number of the audited emergency cesarean sections were performed on doubtful indications. In the light of the rising trend in global cesarean section rates, there seems to be a need to ensure quality of management preceding cesarean sections. This is particularly called for in rural sub-Saharan Africa where cesarean rates are still low and health risks of emergency surgery not negligible.