DOI: 10.1111/j.1471-0528.2012.03284.x www.bjog.

org

General obstetrics

Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals
N Maale,a BL Sorensen,b R Onesmo,c NJ Secher,d IC Bygbjerga
Department of International Health, Immunology, and Microbiology, University of Copenhagen, Copenhagen b Department of Gynaecology and Obstetrics, Roskilde University Hospital, Roskilde, Denmark c Sekou-Toure Regional Hospital, Nyamagana DC, Mwanza, Tanzania d The Research Unit Womens and Childrens Health, The Juliane Marie Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark Correspondence: Dr N Maale, Department of International Health, Immunology, and Microbiology, University of Copenhagen, Struenseegade 33, 4. th, DK 2200 Copenhagen, Denmark. Email nanna_maal@hotmail.com Accepted 30 December 2011. Published Online 14 February 2012.
a

Objective To audit the quality of obstetric management preceding

emergency caesarean sections for prolonged labour.

Design A quality assurance analysis of a retrospective criterionbased audit supplemented by in-depth interviews with hospital staff. Setting Two Tanzanian rural mission hospitals. Population Audit of 144 cases of women undergoing caesarean sections for prolonged labour; in addition, eight staff members were interviewed. Methods Criteria of realistic best practice were established, and

Results Suboptimal management was identied in most cases. Non-invasive interventions to potentially avoid operative delivery were inadequately used. When deciding on caesarean section, in 26% of the cases labour was not prolonged, and in 16% the membranes were still intact. Of the women with genuine prolonged labour, caesarean sections were performed with a fully dilated cervix in 36% of the cases. Vacuum extraction was not considered. Amongst the hospital staff interviewed, the awareness of evidence-based guidelines was poor. Word of mouth, personal experience, and fear, especially of HIV transmission, inuenced management decisions. Conclusion The lack of use and awareness of evidence-based

the case les were audited and compared with these. Hospital staff were interviewed about what they felt might be the causes for the audit ndings.
Main outcome measures Prevalence of suboptimal management

guidelines led to misinterpretation of clinical signs, fear of simple interventions, and an excessive rate of emergency caesarean sections.
Keywords Caesarean section, criterion-based audit, developing

and themes emerging from an analysis of the transcripts.

country, oxytocin, prolonged labour, vacuum extraction.

Please cite this paper as: Maale N, Sorensen B, Onesmo R, Secher N, Bygbjerg I. Prolonged labour as indication for emergency caesarean section: a quality assurance analysis by criterion-based audit at two Tanzanian rural hospitals. BJOG 2012;119:605613.

Introduction
Sub-Saharan Africa carries the worlds highest burden of maternal and perinatal mortality. With approximately 790 maternal deaths per 100 000 live births and 69 perinatal deaths per 1000 total births, Tanzania is no exception.1,2 The United Nations fourth and fth Millennium Development Goals and related intervention programmes have not yet impacted on this birth-related mortality, and Africa as a whole is not on track to meet the goals.3 Universal access

to skilled birth attendance is recommended,35 yet the quality of hospital obstetric care in sub-Saharan Africa is often reported as poor, and efforts are needed to address this contributing factor to maternal and perinatal mortality.613 Prolonged labour (PL) is an important risk factor for birth-related complications, including fetal distress, which may lead to neurological damage or perinatal death, and maternal complications such as postpartum haemorrhage, uterine rupture, puerperal sepsis, and obstetric stulae.14,15 In these cases, access to skilled birth attendants and use of

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the WHOs partograph are crucial to secure adequate surveillance and timely action.16,17 The causes of PL or labour dystocia are mainly the following: poor power of contractions, malpresentation, malposition, and disproportion between the maternal pelvis and fetal head.18 True cephalopelvic disproportion can only be diagnosed antepartum if there is a grossly abnormal pelvis or obvious fetal hydrocephalus. In all other situations, a trial of labour is mandatory to diagnose PL.1719 The rst stage of the active phase of labour is prolonged when cervical dilation is <1 cm/hour, dened by the partographs alert line. If this delay exceeds 4 hours, the action line is crossed, and immediate action must be taken. PL in the second stage is dened as a fully dilated cervix for more than 1 hour in a multiparous woman and 2 hours in primigravidae.17 This study investigated the extent and causes of suboptimal care at two Tanzanian rural hospitals. Using criterionbased audit (CBA), the management preceding emergency caesarean sections was assessed.20 This paper presents ndings of the study in a subpopulation where the sole indication for emergency caesarean section was PL. To understand underlying reasons for suboptimal care, indepth interviews were conducted with the hospital staff.21

Criterion-based audit
The rst three steps of the CBA cycle were applied (Figure 1).20 The rst step was to establish audit criteria for the management of PL, accounting for best achievable practices when considering the resources available. The selected criteria were adapted from ODriscoll et al.s Active management of labour package, modied by the WHO, and supplemented with other evidence-based guidelines.1719,22 The criteria were compared with Tanzanian Ministry of Health guidelines.23,24 The active phase of labour was dened in the national guidelines as starting at a cervical dilation of 3 cm, but was dened by the WHO as starting at 4 cm.17 To enable the use of the national guidelines, both

Management preceding emergency caesarean sections due to the indication of prolonged labour How was the care given? Step 1: Establishing relevant audit criteria of good practice Step 5: Re-evaluation and refinement The criterion-based audit cycle Step 4: Recommendations and implementing changes Step 3: Analysis of findings Why was the care suboptimal? Step 2: Data collection

Methods
The study took place at two mission hospitals in neighbouring rural districts of Tanzania. Both facilities had about 200 beds and provided comprehensive emergency obstetric care, with the exception of instrumental vaginal delivery. Births were attended by nurse-midwives (NMs), assistant medical ofcers (AMOs), and, occasionally, medical ofcers (MOs). NMs had a 4-year diploma in nursing and midwifery. AMOs had 3 years of training before graduation, and were responsible for clinical management and surgery in the absence of MOs. Hospital A was a designated district referral hospital where no user fees for delivery care were required. Hospital B charged user fees (vaginal delivery, $11; caesarean section, $19) and accepted few referrals. In 2009, hospital A reported 13 maternal deaths out of 3054 deliveries and a perinatal death rate of 74 deaths per 1000 births. In the same year, hospital B reported one maternal death out of 1072 deliveries and 45 perinatal deaths per 1000 births. The yearly caesarean section rate exceeded 20% at both facilities. Ofcial permission to conduct this quality assurance analysis was obtained from the respective authorities of both hospitals. The Danish National Committee on Biomedical Research Ethics approved the study. The identities of the hospitals are kept condential, and the staff interviewed provided informed consent.

Staff reflections by in-depth interviews

Participatory observations

Presentation of the findings for health care providers and hospital management at the study sites
Figure 1. Data collection methods applied in the present quality assurance analysis.20,21 Steps 4 and 5 of the criterion-based audit cycle are not included the present study.

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3- and 4-cm dilations were audited as acceptable practice. Otherwise, no major conicts were found, but the national as well as international protocols were often not sufciently specic to be used as audit criteria, and therefore various guidelines were combined. For instance, to avoid vertical HIV transmission, the WHO states that if a woman is HIVpositive or it is an area of high prevalence, the membranes must be left intact for as long as possible.17 For the purposes of the audit, this is imprecise, and the Tanzanian guideline was applied: for an HIV-positive woman, articial rupture of the membranes (ARM) is delayed until the cervix is 8-cm dilated.23,24 Additionally, if the action line was crossed, ARM should be applied regardless of HIV status. Drafts of the audit criteria were reviewed by two audit consultants, a Tanzanian and a Danish specialist in obstetrics (co-authors of the paper), as well as by two healthcare providers at each hospital: an NM and an AMO. After a pilot test, nal adjustments were made. Figure 2 illustrates the nal audit criteria organised according to cervical dilation and the partograph. If information was available, the time elapsing from crossing the
Active phase of labour: Second stage

action line until delivery was assessed for cases prolonged in the rst stage of the active phase, and the decision-todelivery intervals (DDIs) were calculated. A DDI of 75 minutes was set as the standard within which delivery by emergency caesarean section should be performed.19 The extent of partograph use was also analysed.17 Data collection for the second step of the CBA took place in July and August 2010. From the 2009 operation theatre records, 200 cases of caesarean section were retrieved at each hospital and cross-checked with the admission and delivery registers. A total of 400 records were used because of the limited period of time for which the rst author was afliated with the hospitals. Of these records, cases where PL was documented as the sole indication for the operation were included in the study (Figure 3). This implied the exclusion of cases where PL was mentioned together with, for instance, fetal distress, breech presentation, intrauterine fetal death, or more than one previous caesarean section, as well as if a grossly abnormal pelvis or hydrocephalic fetus was documented. In these cases, the audit criteria on the management of PL would be misleading.

CD = 10 for 1 hour/2 hours (multi/primi gravida) Prolonged second stage of labour Active management - ARM if membranes are still intact - Oxytocin infusion may be considered 1 hour after ARM if no good labour pattern - VE more frequently than every 4 hours - IVD if descent of fetal head is 1/5 or 0/5 - Delivery by CS as last resort when other options are tried

CD [cm]
10

Active phase of labour: First stage

9 8

CD 1 cm/hour Expectant management

CD <1 cm/hour Active management

- Supportive care only

7 6 5 4

Ale

rt l

ine

- ARM if membranes are still intact - ARM if membranes are still intact (also if HIV-positive) (if HIV-positive, not before - Oxytocin infusion may be considered 1 hour 8 cm of CD) after ARM if no good labour pattern - VE more frequently than line every 4 hours - VE more frequently than every 4 hours n o i - Delivery by CS as last resort when other options are tried Act

Latent phase of labour

3 2 1

- Supportive care only

Time [hours]
1 2 3 4 5 6 7 8 9

10

11

12

At any time during late pregnancy/labour:

Fetal distress QUICK delivery - either by emergency CS or IVD

An absolute indication for CS Elective/Emergency CS

Intrauterine fetal death Cervical delivery - by induction of labour and destructive delivery if needed

Figure 2. An illustration of the criteria audited in the present study, based on the WHO partograph.17 The guideline on articial rupture of membranes in HIV-positive women is adapted from the Tanzanian national standards.23 Fetal distress, which demands immediate action, is dened as a fetal heart rate <100 or >180 beats/minute. Good labour is dened as at least three contractions every 10 minutes, with each contraction lasting at least 40 seconds. Abbreviations: ARM, articial rupture of membranes; CD, cervical dilation; CS, caesarean section; IVD, instrumental vaginal delivery; VE, vaginal examination.

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Figure 3. The sampling of case les. In the present study, only cases of emergency caesarean section with prolonged labour as the sole indication were included. Emergency caesarean sections were dened as all caesarean deliveries not carried out electively at a planned time to suit the woman or staff.19 To reduce the bias of seasonal variation, half of the cases were collected consecutively according to delivery dates from 1 April 2009, and the other half from 1 October 2009.

The research material included case les with partographs, as well as admission, delivery, and operation registers. The rst author extracted the clinical data using a questionnaire, and data were entered in EPI INFO version 3.5.1 software (Centers for Disease Control and Prevention, Atlanta, GA, USA). In cases of doubt when classifying data, the author conferred with the audit consultants. If a practice was not documented, it was assumed that it was not performed.20 The third step of the CBA was to analyse the results to assess the proportion of cases that met the criteria. The ndings were presented to the healthcare providers and management. Local authorities were encouraged to complete the audit cycle by formulating and implementing action plans for quality improvement.20

an NM superintendant, and two NMs at each hospital. Consent was obtained from all participants. Each interview lasted 3065 minutes. Notes were written and the interviews were voice-recorded, transcribed, and coded. Content analysis was used to identify emerging themes.

Results
Criterion-based audit
A total of 400 women giving birth by caesarean section were identied from hospital registers. Sixty-two (16%) les were missing, and these women were excluded. Of the remaining cases, 144 (48%) were emergency caesarean sections performed solely for PL. This latter group met the inclusion criteria, and at both hospitals PL was the single most common indication for emergency caesarean section (Figure 3). Seventy-one (49%) women were primigravidae, and 33 (23%) women had a history of one previous lower segment caesarean delivery. Five (4%) were tested HIV-positive, whereas in 23 (16%) cases the HIV status was not documented. Admission occurred prior to the active phase of

In-depth interviews
To explore hospital staffs explanations of the audit ndings, semi-structured in-depth interviews were conducted in English by the rst author.21 The questions were thematically related to the CBA and open ended. Eight staff members were selected by convenience sampling: an AMO,

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Table 1. Background parameters Characteristics Hospital A No. (n = 81%) Age of mother (years) 19 2029 3039 40 No information Total number of deliveries including present 1 24 >4 No information Previous caesarean sections* 0 1 2 HIV-testing Positive Negative No information Time of admission Before active phase of labour** First stage, active phase of labour Second stage, active phase of labour Time of admission unclear Singleton or twin delivery Singleton Twin Referrals from smaller health centres*** Yes No Hospital B No. (n = 63%) Total No. (n = 144%) OR (95% CI)

17 53 10 1 0 42 33 6 0

(21) (65) (12) (1) (0) (52) (41) (7) (0)

14 24 23 2 0 29 16 18 0

(22) (38) (37) (3) (0) (46) (25) (29) (0)

31 77 33 3 0 71 49 24 0

(22) (53) (23) (2) (0) (49) (34) (17) (0)

0.93 3.08 0.24 0.38

(0.422.07) (1.556.10) (0.110.57) (0.034.30)

1.26 (0.652.44) 2.02 (0.984.15) 0.20 (0.070.54) 0.67 (0.301.50) 1.49 (0.673.32) 0.51 (0.083.13) 1.37 (0.603.13) 0.82 (0.342.01) 0.18 (0.080.38) 3.76 (1.758.07) 0.78 (0.0512.64) 21.70 (2.83166.40) 0.05 (0.010.35)

60 (74) 21 (26) 0 (0) 2 (2) 67 (83) 12 (15) 33 38 9 1 (41) (47) (11) (1)

51 (81) 12 (19) 0 (0) 3 (5) 49 (78) 11 (17) 50 12 0 1 (79) (19) (0) (2)

111 (77) 33 (23) 0 (0) 5 (3) 116 (81) 23 (16) 83 50 9 2 (58) (35) (6) (1)

80 (99) 1 (1) 21 (26) 60 (74)

63 (100) 0 (0) 1 (2) 62 (98)

143 (99) 1 (1) 22 (15) 122 (85)

*All previous caesarean sections were described as lower segment caesarean sections. If more than one previous caesarean section was documented, the case was excluded from the study. **Cervical dilatation <4 cm. ***Of the 22 referrals, three were admitted at the study sites before active labour, 11 in rst stage of active phase of labour, and eight in second stage of labour.

labour for 83 (58%) women, whereas 50 (35%) and nine (6%) women were admitted in the rst and second stages of the active phase, respectively. There were 22 referrals from smaller facilities. Regarding maternal age, time of admission, and number of referrals, the population proles were signicantly different between the study sites (Table 1). In the following sections, the process of delivering obstetric care is described, and Table 2 presents the main results for each hospital. Of the women included, 39 (27%) were not assessed by an (A)MO prior to the emergency caesarean section. In these cases, the initial comment by the doctor regarding PL was a description of the operation. In 23 (17%) of the cases where admission happened prior to the second stage, the partograph was not used.

In 37 (26%) cases, it was clearly documented that labour was not prolonged when deciding on emergency caesarean section, and the vital signs of the woman and fetus were normal. In 23 (16%) cases, the membranes were still intact when deciding on the operation. In 97 (67%) women, it was substantiated that labour was actually prolonged when deciding on emergency caesarean section: 62 (64%) women were prolonged in the rst stage of the active phase, whereas 35 (36%) women were prolonged in the second stage. Vacuum extraction was never attempted. Nine (9%) women received a trial of augmentation by oxytocin. In the women with genuine PL in the rst stage of the active phase, it was possible to calculate the time from

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Table 2. Process parameters. Suboptimal management found by the criterion-based audit of cases where emergency caesarean section was performed because of the indication of prolonged labour Management Hospital A No. (%) Women admitted before second stage of labour, but partograph not used* No documented consultation by doctor prior to caesarean section** HIV status not tested** Labour not prolonged**,*** Alert/action line crossed, but 4 hours to next vaginal examination**** Membranes intact, but articial rupture not performed at rst vaginal examination after crossed alert/action line**** Intact membranes when emergency caesarean section decided upon** Emergency caesarean section performed when cervix fully dilated, no trial of vacuum extraction conducted***** 13 15 12 26 23 12 (18) (19) (15) (32) (77) (40) Hospital B No. (%) 10 24 11 11 23 17 (16) (38) (17) (17) (72) (53) Total No. (%) 23 39 23 37 46 29 (17) (27) (16) (26) (74) (47) 1.17 0.37 0.82 2.24 1.29 0.59 (0.472.88) (0.170.79) (0.342.01) (1.004.98) (0.414.04) (0.211.61) OR (95% CI)

9 (11) 18 (38)

14 (22) 17 (35)

23 (16) 35 (36)

0.44 (0.181.09) 1.13 (0.492.59)

*Percentage of all women admitted before second stage of labour (A, n = 71; B, n = 62). **Percentage of all women included in the audit (A, n = 81; B, n = 63). ***Labour not prolonged, was dened as the alert line not crossed in rst stage of labour, or second stage of labour having lasted <1 or 2 hours for a multipara or primigravida, respectively. ****Percentage of all women where labour was actually prolonged in rst stage of active phase of labour (A, n = 30; B, n = 32). *****Percentage of all women where labour was actually prolonged (A, n = 48; B: N = 49).

crossing the action line to delivery in 53 (86%) cases. The median time was 6 hours, ranging from 0 to 25 hours. The DDI was calculated in 70 (49%) of all cases. In 40 (57%) of these, the DDI exceeded 75 minutes. The median DDI was 84 minutes, ranging from 15 minutes to 7 hours.

It was agreed that women were often assessed inefciently, especially regarding fetal heart rate and contractions. It was stressed that cervical dilation was monitored reliably. One midwife, how can you manage to make sure that you stay with every mother 10 minutes counting contractions, and the others are pushing?We just imagine: contractions three, fetal heart rate 134, but it is not supposed to be like that. (NM2) The staff recognized that ARM was rarely undertaken. A common explanation was fear of vertical HIV transmission and the risk of seroconversion after testing. You regard them [pregnant women] as at risk You can screen her today, and the next day she is not [HIV] negative. (NM superintendant 1) Formerly, every midwife knew at what stage they were supposed to rupture the membranes. But then later on when HIV came, and they told us to do this programme of PMTCT [Primary Mother To Child Transmission] for women who were infected with HIV, they said that you should not rupture the membranesit seemed like that it [sic] was for every woman. (NM superintendant 2) The answers as to why instrumental vaginal delivery was no longer in use differed. Vacuum extraction is badthe child will end up with mental problems, and another will go with hydrocephalusso you are not advised to use it. (NM3)

In-depth interviews
A shortage of skilled birth attendants was mentioned repeatedly as a cause for the suboptimal management revealed by the CBA. Here we have six beds [for deliveries], and there are times where you have ten cases waiting and everyone [is] about fully dilated...you nd that it is overwhelming. (AMO1) My management will not be appropriate. It is just, remove the baby, you put it there and you go to another woman... (NM1) The impression was that obstetric management was uniform among providers. Yet, when asked which obstetric guidelines were used, the answers varied. Now we dont have guidelines here in [the] maternity wardI think we do what we see, and what we have been learned [sic] at the school. (NM2) Sometimes we receive a gynaecologist with guidelines. Sometimes we get guidelines from a workshop Guidelines, they are mixed. (NM superintendant 1)

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People some say that this is modern obstetrics [not to use vacuum extraction], but I dont think that it isI dont know exactly where it came from. It could be the same reasons for ARM: due to the incidences of high HIV/AIDS. (AMO1) Regarding the decision process on emergency caesarean section, organisational issues appeared to be central. You may call the doctor and say that there is a mother with a problem, and he says prepare the mother and go to the theatre for C-section [caesarean section]. (NM1) Sometimes we [NMs] dont agree with them [(A)MOs]. So what we do sometimes is to take the mother to the [operation] theatre and say: If you dont want to do C-section [caesarean section], then you stay with this mother. (NM3)

Discussion
An emergency caesarean section can be life saving, but it is also associated with increased maternal morbidity and mortality.25,26 This paper provides a detailed account on a specic quality assurance intervention in a Tanzanian resource-poor setting. It highlights various problems related to the quality of intrapartum care in cases of PL, leading to unnecessary emergency caesarean sections. Adequate monitoring during labour was lacking, non-invasive interventions were inadequately used, and vacuum extraction was not performed. The interviews indicated a poor awareness of evidence-based guidelines, whereas word-of-mouth, personal experience, and fear inuenced management. The CBA appeared useful as a structured and low-cost method for quality assurance in an under-resourced setting. The risk of bias when selecting the audit criteria was addressed by using evidence-based guidelines and having the audit consultants reviewing them.1719 Once decided, the audit criteria were simple and unambiguous to apply. This minimised bias from a subjective analysis, and the data collection did not rely on obstetric specialists. Additionally, the partograph schema was simple and clear to use for classifying data, presenting the audit ndings, and formulating recommendations (Figure 2). However, bias may have occurred because of missing information in the case les. A further limitation is the lack of documentation regarding other aspects of obstetric care, such as continuous professional attendance, change in position, ambulation, and adequate nutrition.22 Additionally although the effectiveness of the CBA method has been reported elsewhere quality assurance projects call for follow-up in order to assure their impact.6,20,2729 Interestingly, signicant differences were found between the neighbouring rural mission hospitals studied, regarding

the population proles and in the ofcial birth-related mortality statistics from 2009 (Table 1). This might be suggested to be a central nding when considering the validity of one-centre audits in formulating widespread intervention strategies for low-income countries. On the other hand, the process parameters, interviews, and participatory observations on obstetric care given were comparable between the study sites, and similar to other reports from the region, suggesting that these management issues may be more widespread (Table 2).713 The in-depth interviews and eye-witness observations added valuable information on the causes for the suboptimal care indentied by the CBA. Interviews are by nature subjective, not objective, and qualitative data are contextual, and inuenced by both the researcher and informants. This also applies to interview topics, to respondents answers, which are likely to be inuenced by perceived potential negative consequences, and to the analysis of transcripts. Neither national nor international guidelines were followed routinely, and the staffs explanations of the care provided were, primarily, based on word of mouth, personal experience, and fear. Mixed sources of guidelines caused confusion, leaving the staff without a clear statement of what was expected. Standards of care are needed that are simple, relevant, and achievable in under-resourced settings.30 International as well as Tanzanian national guidelines highlight vacuum extraction as a central obstetric function.17,18,23,24 This mode of delivery is considered safe and effective in an under-resourced setting.31 Yet, it was abolished at the study sites, and the decline in instrumental vaginal deliveries is reported from both high- and lowincome countries.9,11,32,33 The fear of vertical HIV transmission mentioned during the present interviews may explain the reluctance to use vacuum extraction and ARM. Only four percent of the women were tested as being HIVpositive, but the interviews revealed that staff had little condence in HIV screening. All women were regarded as potentially HIV positive, in which case vacuum extraction may be contraindicated.17,23,34 During the last decade, worldwide efforts have established guidelines for HIV/AIDS, whereas the implementation of obstetric guidelines remains less united and thorough.9,10,29,35 As commented in the in-depth interviews, it may be hypothesised that this has weighted the fear of obstetric complications towards fear of vertical HIV transmission. This is an example of frail health systems being additionally compromised by over-concentrating resources in one specic programme, leaving other areas further under-resourced.36 Only nine women received augmentation by oxytocin, which may have been because of a fear of complications: uterine hyperstimulation and fetal heart rate abnormalities.14,17 This might be sensible in the constrained work

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conditions of the study sites. To meet the WHOs recommendations, contractions must be assessed for 10 minutes, half-hourly, in the rst stage of the active phase, implying that one NM would have a full-time job counting contractions in three labouring women. Additionally, 17% of the women in the CBA had a history of more than four previous deliveries, and 23% had a previous caesarean section. In both cases, the risk of oxytocin-induced uterine rupture may be increased.14,37 On the other hand, 49% were primigravidae who are more likely to have weak contractions and be less susceptible to uterine rupture.22 Strikingly, in 26% of women, labour was progressing normally when emergency caesarean section was decided on for PL, and in almost one-third of all cases, the (A)MO who performed the emergency caesarean section seemed not to have been involved in the decision on mode of delivery. These ndings, together with the reluctant use of augmentation and vacuum extraction, may indicate that a considerable number of emergency caesarean sections were unnecessary. Needless surgery was thus posing an unacceptable threat to the health of women in current and future pregnancies as well as of children, and adding unnecessary costs for poor women and health systems.25,26 Finally, a median DDI of 84 minutes with a maximum of 7 hours is unacceptable, and requires a change in the organisational decision-making processes for emergency caesarean sections.19

Disclosure of interests
The authors have no conicts of interest to disclose.

Contribution to authorship
The study originates from the Department of International Health, Immunology, and Microbiology, University of Copenhagen, Denmark, but the eldwork and data collection took place at two mission hospitals in Kagera Region, Tanzania: NM, development of the study design, selection of audit criteria, acquisition of data, analysis and interpretation of data, drafting the article, and nal approval of the version to be published; BLS, development of the study design, selection of audit criteria, analysis and interpretation of data, repeated critical revision of the article, and nal approval of the version to be published; RO, development of the study design by critically revising the audit criteria, revising the article critically, and nal approval of the version to be published; NJS, development of the study design by critically revising the audit criteria, revising the article critically, and nal approval of the version to be published; ICB, development of the study design, analysis and interpretation of data, repeated critical revision of the article, and nal approval of the version to be published.

Details of ethics approval

On enquiry to The Danish National Committee on Biomedical Research Ethics, we were assured that this quality assurance analysis did not need an ethical assessment according to Danish law. Prior to the data collection, ofcial permission to conduct the research was obtained from the respective authorities at both hospitals.

Conclusion
In the present study, the failure to use evidence-based guidelines led to inconsistent management, misinterpretation of clinical signs, fear of safe and low-cost obstetric interventions, and an excessive rate of emergency caesarean sections. Reducing the emergency caesarean section rate might liberate both time and resources if replaced with basic low-cost obstetric interventions, as presented in Figure 2, and our ndings cannot primarily be explained by a shortage of essential equipment or staff. We recommend that simple uniform guidelines on obstetric care that are not just rational but represent realistic best practice are introduced and enforced at health facilities comparable with those of the present study. Training is needed for decision making in emergency caesarean section, so that vacuum extraction, ARM, and oxytocin can be provided safely. The focus on avoiding HIV transmission is crucial, but it must be weighed against the risk of maternal and perinatal complications caused by poor obstetric management. Finally, the use of a partograph is critical for timely surveillance and action. These interventions for the active management of labour have proven their value for the last 38 years, but effective implementation is required.22,38

Funding
This work was supported by a grant from Danida Fellowship Centre, The Danish Ministry of Foreign Affairs. It supports thesis eldwork of master students enrolled at Danish higher educational institutions. For more information, please see: http://www.dfcentre.com.

Acknowledgements
We thanks all staff members at both study sites for their comprehensive cooperation and their contributions to the present study. j

References
1 World health Organization, World B, UNICEF, United Nations Population Fund. Trends in Maternal Mortality 1990 to 2008. Geneva: World Health Organization, 2010. 2 World health Organization. Neonatal and Perinatal Mortality: Country, Regional and Global Estimates. Geneva: WHO, 2006. 3 United Nations. Achieving the Millenium Development Goals in Africa: Recommendations of the MDG Africa Steering Group. New York, NY: United Nations, 2008.

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