Timing of cesarean section for prolonged labor in urban Tanzania: A criterion-based audit

Abstract

BACKGROUND

Similar to many resource-constrained urban settings, cesarean deliveries in Dar es Salaam, Tanzania, have increased rapidly, from 17% in 2015 to 26% in 2022. Alarmingly, at the population level, the increase was not followed by improvements in perinatal outcomes, suggesting the overuse of cesarean delivery. Prolonged labor is the leading cause of women's first cesarean delivery. Therefore, understanding the management of prolonged labor preceding cesarean delivery is crucial for preventing nonmedically indicated cesarean deliveries across Tanzania and globally.

OBJECTIVE

This study aimed to estimate the proportion of cesarean deliveries with a written indication of prolonged labor that was performed in labors with uncomplicated progression.

STUDY DESIGN

This study was conducted at 5 urban maternity units in Dar es Salaam, Tanzania, from October 1, 2021, to August 31, 2022. Data were extracted from case files of women who gave birth via cesarean delivery with a written indication of prolonged labor. The timing of cesarean delivery decision was assessed against predefined definitions of prolonged labor at each stage/phase of labor. The proportion of cesarean deliveries performed in cases of uncomplicated progression was calculated. The exclusion criteria included referral to study sites because of prolonged labor or cervical dilatation of >6 cm upon admission, noncephalic presentation, multiple pregnancy, intrauterine fetal death, failed induction of labor, previous cesarean delivery, or other written indications for cesarean delivery.

RESULTS

The overall cesarean delivery rate was 32% (2949/9364). Of first-time cesarean delivery cases, 746 of 1517 patients (47.9%) had a written indication of prolonged labor. Finally, 456 of 746 patients (61.1%) met the inclusion criteria, of which 307 of 456 patients (67.3%) were admitted in the latent phase of labor. In 243 of 456 cesarean deliveries (53.3%) with an indication of prolonged labor, labor was not prolonged. This group included (1) women not being given a trial of labor (78/243 [32.1%]), (2) women in the first stage of active labor not crossing the partograph action line (145/243 [59.7%]), and (3) women in the second stage of labor lasting <1 hour (20/243 [8.2%]). Of note, 78 of 346 women (21.5%) in the first stage of active labor had a labor progression faster than 0.5 cm per hour preceding the decision for cesarean delivery.

CONCLUSION

Almost half of cesarean deliveries in unscarred uteri were because of prolonged labor. Despite a written indication of prolonged labor, approximately half of the cases did not have prolonged labor. Although care in low-resource settings has traditionally been categorized as “too little, too late,” this study finds care as “too much, too soon” in one of the world's fastest-growing urban areas. This finding highlights the inadequacy of one-size-fits-all approaches in curbing the increases in cesarean delivery occurring in (pockets of) low-resource settings. Our study calls for ways to respectfully allow more time for physiological labor progression in busy high-volume maternity units where many births occur.