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      Caesarean section audit to improve quality of care in a rural referral hospital in Tanzania

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          Abstract

          Background

          Caesarean section (CS) is often a life-saving procedure, but can also lead to serious complications, even more so in low-resource settings. Therefore unnecessary CS should be avoided and optimal circumstances for vaginal delivery should be created. In this study, we aim to audit indications for Caesarean sections and improve decision-making and obstetric management.

          Methods

          Audit of all cases of CS performed from January to August 2013 was performed in a rural referral hospital in Tanzania. The study period was divided in three audit blocks; retrospective (before auditing), prospective 1 and prospective 2. A local audit panel (LP) and an external auditor (EA) judged if obstetric management was adequate and indications were appropriate or if CS could have been prevented and yet retain good pregnancy outcome. Furthermore, changes in modes of deliveries, overall pregnancy outcome and decision-to-delivery interval were monitored.

          Results

          During the study period there were 1868 deliveries. Of these, 403 (21.6%) were Caesarean sections. The proportions of unjustified CS prior to introduction of audit were as high as 34 and 75%, according to the respective judgments of LP and EA. Following introduction of audit, the proportions of unjustified CS decreased to 23% ( p = 0.29) and 52% ( p = 0.01) according to LP and EA respectively. However, CS rate did not change (20.2 to 21.7%), assisted vacuum delivery rate did not increase (3.9 to 1.8%) and median decision-to-delivery interval was 83 min (range 10 - 390 min).

          Conclusions

          Although this is a single center study, these findings suggest that unnecessary Caesarean sections exist at an alarming rate even in referral hospitals and suggest that a vast number can be averted by introducing a focused CS audit system. Our findings indicate that CS audit is a useful tool and, if well implemented, can enhance rational use of resources, improve decision-making and harmonise practice among care providers.

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          Most cited references 22

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          Caesarean section without medical indications is associated with an increased risk of adverse short-term maternal outcomes: the 2004-2008 WHO Global Survey on Maternal and Perinatal Health

          Background There is worldwide debate about the appropriateness of caesarean sections performed without medical indications. In this analysis, we aim to further investigate the relationship between caesarean section without medical indication and severe maternal outcomes. Methods This is a multicountry, facility-based survey that used a stratified multistage cluster sampling design to obtain a sample of countries and health institutions worldwide. A total of 24 countries and 373 health facilities participated in this study. Data collection took place during 2004 and 2005 in Africa and the Americas and during 2007 and 2008 in Asia. All women giving birth at the facility during the study period were included and had their medical records reviewed before discharge from the hospital. Univariate and multilevel analysis were performed to study the association between each group's mode of delivery and the severe maternal and perinatal outcome. Results A total of 286,565 deliveries were analysed. The overall caesarean section rate was 25.7% and a total of 1.0 percent of all deliveries were caesarean sections without medical indications, either due to maternal request or in the absence of other recorded indications. Compared to spontaneous vaginal delivery, all other modes of delivery presented an association with the increased risk of death, admission to ICU, blood transfusion and hysterectomy, including antepartum caesarean section without medical indications (Adjusted Odds Ratio (Adj OR), 5.93, 95% Confidence Interval (95% CI), 3.88 to 9.05) and intrapartum caesarean section without medical indications (Adj OR, 14.29, 95% CI, 10.91 to 18.72). In addition, this association is stronger in Africa, compared to Asia and Latin America. Conclusions Caesarean sections were associated with an intrinsic risk of increased severe maternal outcomes. We conclude that caesarean sections should be performed when a clear benefit is anticipated, a benefit that might compensate for the higher costs and additional risks associated with this operation.
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            Trends in caesarean delivery by country and wealth quintile: cross-sectional surveys in southern Asia and sub-Saharan Africa

            Objective To examine temporal trends in caesarean delivery rates in southern Asia and sub-Saharan Africa, by country and wealth quintile. Methods Cross-sectional data were extracted from the results of 80 Demographic and Health Surveys conducted in 26 countries in southern Asia or sub-Saharan Africa. Caesarean delivery rates were evaluated – as percentages of the deliveries that ended in live births – for each wealth quintile in each survey. The annual rates recorded for each country were then compared to see if they had increased over time. Findings Caesarean delivery rates had risen over time in all but 6 study countries but were consistently found to be lower than 5% in 18 of the countries and 10% or less in the other eight countries. Among the poorest 20% of the population, caesarean sections accounted for less than 1% and less than 2% of deliveries in 12 and 21 of the study countries, respectively. In each of 11 countries, the caesarean delivery rate in the poorest 40% of the population remained under 1%. In Chad, Ethiopia, Guinea, Madagascar, Mali, Mozambique, Niger and Nigeria, the rate remained under 1% in the poorest 80%. Compared with the 22 African study countries, the four study countries in southern Asia experienced a much greater rise in their caesarean delivery rates over time. However, the rates recorded among the poorest quintile in each of these countries consistently fell below 2%. Conclusion Caesarean delivery rates among large sections of the population in sub-Saharan Africa are very low, probably because of poor access to such surgery.
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              Incidence and risk patterns of venous thromboembolism in pregnancy and puerperium--a register-based case-control study.

              This study was undertaken to estimate the incidence of venous thromboembolism in pregnancy and puerperium and to identify risk factors for pregnancy-related venous thromboembolism. A register-based case-control study with 613,232 pregnancies from 1990-2003 in 11 Norwegian counties. Medical records for eligible cases were revisited and relevant medical data were transferred to a specific case-report form. The diagnosis of venous thromboembolism was based on strict criteria. Data were analyzed by chi2 test and forward stepwise logistic regression. In total, 615 cases were detected. The incidence of venous thromboembolism was 1 per 1000 pregnancies. The ante- and postnatal incidences were quite similar. Antenatal risk factors were assisted reproduction, gestational diabetes, age older than 35 years, multiple pregnancies, and primi-parity. Postnatal risk factors were cesarean section, preeclampsia, assisted reproduction, abruptio placenta, and placenta previa. We found different ante- and postnatal risk patterns. Assisted reproduction and gestational diabetes were significant antenatal risk factors; whereas cesarean section and preeclampsia were strong postnatal risk factors.
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                Author and article information

                Contributors
                dekkerluuk@gmail.com
                tessa.houtzager@gmail.com
                omarykilume@yahoo.com
                horogoillan@yahoo.com
                j.j.m.van_roosmalen@lumc.nl
                nyamtema_angelo@yahoo.co.uk , anyamtema@ttcih.ac.tz
                Journal
                BMC Pregnancy Childbirth
                BMC Pregnancy Childbirth
                BMC Pregnancy and Childbirth
                BioMed Central (London )
                1471-2393
                15 May 2018
                15 May 2018
                2018
                : 18
                Affiliations
                [1 ]Department of Obstetrics and Gynaecology, St. Francis Referral Hospital, Ifakara, Tanzania
                [2 ]ISNI 0000000089452978, GRID grid.10419.3d, Department of Obstetrics, , Leiden University Medical Centre, ; Leiden, The Netherlands
                [3 ]St. Francis University College of Health and Allied Sciences, P.O Box 175, Ifakara, Tanzania
                Article
                1814
                10.1186/s12884-018-1814-1
                5952645
                29764384
                © The Author(s). 2018

                Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License ( http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver ( http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

                Categories
                Research Article
                Custom metadata
                © The Author(s) 2018

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