Tanzanian study finds many potentially avoidable cesarean sections amid global rise

A new major study of about 3000 caesarean sections in Dar es Salaam, Tanzania, highlights this challenge. With rapid urban growth putting pressure on maternity wards in one of the world’s fastest growing cities, the study found high numbers of cesarean deliveries without clear medical reasons.

Read the study published at the American Journal of Obstetrics and Gynecology Global Reports.

“The sharp contrast between low national cesarean rates and the much higher rates seen in urban areas raises the need to examine what is driving this trend, particularly given the risks and complications associated with cesarean delivery’’, says Dr. Brenda Sequeira Dmello, obstetrician and gynaecologist in Dar es Salaam.

Globally, the cesarean section rate has climbed to 21.1% and is projected to hit 28.5% by 2030. While cesarean sections remain a vital tool in obstetrics to save lives, the rapid increase has raised concerns among maternal health experts about potential overuse and associated risks.

We are facing a cesarean section pandemic.

- Dr. Sarah Hansen, medical doctor and researcher, PartoMa project

Hansen participated on a team of researchers from Aga Khan University Tanzania, Aarhus University, the University of Copenhagen and Vrije University Amsterdam, examining clinical decision-making in medical records of five of the busiest maternity units in Dar es Salaam to understand why cesarean sections were being performed. The evidence-based audit criteria, co-developed with local clinicians, found that 32% of all births were by cesarean section — and 40% of those had no valid medical indication based on the pre-defined, localised clinical criteria.

“Among the most common reasons for these cesarean sections were one previous cesarean section without offering a trial of labor, suspected prolonged labor without documented  evidence of slow labour progress, and fetal distress despite normal fetal heart rate at the time of decision,” explains Hansen.

Alarmingly, the study also found that most women who needed an urgent, unplanned cesarean waited hours before reaching the operating room. Only 9% had the surgery within one hour of the decision being made. That means that the vast majority experienced delays, likely due to busy operating rooms and staff shortages.

“These delays can be dangerous, especially when fast action is critical to save the life of the mother or baby. And perhaps reducing unnecessary cesarean section can reduce waiting time for those experiencing life threatening emergencies”, adds Dmello.

In sub-Saharan Africa, about 1 in 100 women and 8 in 100 newborn babies die during or after a ceserean section. This is 100 times higher for mothers and 50 times higher for babies compared to high-income countries. For this reason, performing cesarean sections without a clear medical need is particularly worrying in sub-Saharan Africa, as it puts both mothers and babies at greater risk. Moreover, cesarean sections can also cause problems in future pregnancies, including tearing of the womb or the placenta attaching in the wrong place — risks that are especially concerning in countries where women often have many children.

“Curbing unnecessary cesarean sections is not just about reducing numbers and resources spent — it’s about safeguarding women’s health and making sure limited resources are used where they’re needed most to ensure best possible care for all women,” Hansen highlights.

A city under pressure

Dar es Salaam is one of the world’s fastest-growing cities. Like many urban centers across sub-Saharan Africa, it is grappling with rapid urbanization, urban poverty, growing birth rates, strained healthcare infrastructure, and critical staff shortages.

In one of Dar es Salaam’s busiest maternity units, you step in to the labour room, where women are struggling with contractions, two in each bed, no analgesia available, midwives attending up to seven women simultaneously with limited number of monitoring devices. Each maternity unit only has one operating theatre for both planned and unplanned obstetric surgeries.

Discussions with local obstetricians revealed the tough pressure and medical dilemma local birth attendants experience while providing care in the crowded resource-constrained environment. In busy labor wards with too few health care workers and not enough equipment, doctors are forced to make difficult choices. Without enough nurses or proper monitoring tools, vital signs can go unchecked and emergencies can be missed. This lack of routine monitoring and care may increase fear among healthcare providers of vaginal birth.

“A fetal heart can drop suddenly, or a scarred uterus can rupture, and in well-equipped hospitals the baby would be delivered within ten minutes,” Dmello explained. “Here, the operating theaters are often full. We fear we won’t get in on time.”

This fear, coupled with the risk of blame if complications occur, drives what doctors call “defensive decision-making”, performing cesareans preemptively rather than risking catastrophe, which in turn perpetuates a vicious cycle.

A pattern in real-world practices across Africa

“Similar patterns are seen beyond Tanzania,” Hansen says. “More than half of global births now occur in urban areas, but health systems in many cities simply haven’t kept pace with the higher demand for facility births.”

The drivers identified in Dar es Salaam mirror trends in other urban areas in Kenya, Malawi, and beyond, where the rising cesarean ection rates often coincide with a growing urban disadvantage in maternal and perinatal health.

“Our findings emphasize the need for structural changes to ensure urban healthcare systems offer best possible care for everyone with the resources available,” Hansen says.

“This means shifting towards a structural collective-oriented approach in decision-making and away from an individual resource-consuming approach where some women experience too much care, too soon and others too little care, too late,” adds Hansen who emphasised that this shift is of crucial importance, as the demand for facility births is growing faster than health systems can keep up. We can’t afford to let clinical care to fall behind.”

The ultimate goal is to create maternity units that support safe vaginal births while ensuring timely access to cesarean section when needed.

The researchers on the PartoMa Project stresses that these findings highlight the need for regular reviews of how cesarean decisions are made, clearer guidelines adapted to local realities, and stronger investments in maternity care—especially in fast-growing cities.

Contact:

Sarah Hansen
Researcher in The PartoMa Project,
Department of Public Health, University of Copenhagen,
Medical Doctor, Zealand Univeristy Hospital, Koege
sarah95dk@gmail.com

Joyce Anne Quinto
Project and Communications Manager
School of Global Health
joyce.quinto@sund.ku.dk