Strategies to reduce the caesarean section rate at a regional hospital in northern KwaZulu-Natal Province, South Africa

Abstract

Background. The caesarean section (CS) rate at Queen Nandi Regional Hospital (QNRH) in northern KwaZulu-Natal Province, South frica (SA), has remained above the national average for a public hospital in SA. In view of the short- and long-term complications of CS, effective strategies are required to reduce unnecessary CS.

Objectives. To identify the indications for CS and the factors that contributed to the high CS rate at QNRH, with the aim of implementing interventions to reduce unnecessary and avoidable CS without compromising mother and baby outcomes.

Methods. We conducted a 3-month retrospective audit (Q1 2024) of 100 randomly selected CS files from the labour ward birth register and from the postnatal ward. The data collected included patient demographics, referring facilities, CS category, indication for CS, Robson Ten Group classification, timing of CS, and maternal and perinatal outcomes. The CS rate for Q1 2024 was compared with Q2 2024 and Q3 2024 with and without local clinic deliveries. Referrals from the local clinics for CS in Q1 2024 were compared with institutional audits from 2020 and 2023. Tables and figures were used for analysis. Institutional ethics permission was obtained for the clinical audit and publication of the data.

Results. During the study period, there were 2 077 deliveries in total and 1 366 CSs, giving a CS rate of 66%. Among the 100 randomly selected files analysed, there were 1 set of twins, 5 stillbirths (3 due to abruptio placentae grade 3b), 96 live births, and no maternal deaths. Of the patients, 44% were aged >20 - 30 years, 41% were in their first pregnancy, 70% were referred from our local clinics, and 48% were low risk; 26% had a body mass index >40 kg/m2, 15% were hypertensive, and 25% were HIV positive. In 47% of cases the indication for CS was fetal distress/non-reassuring cardiotocograph, followed by failed induction of labour (13%), failure to progress (6%), and breech presentation and abruptio placentae (5% each). More than 80% were urgent CSs, with more of these done during the night than during the day (37% v. 28%). A further 22% of the urgent CS were done during changeover time. Of the infants, 72% were born at a gestational age of 34 - 40 weeks and 80% had a birthweight of >2 500 - 4 000 g. All liveborn infants had a normal Apgar score. There were no maternal adverse outcomes. As expected, and owing to the short time frame for repeat in-depth analysis, there was no significant impact of CS trends when comparing Q1 2024 with Q2 and Q3 2024 for both institutional-based and population-based CS rates. Referrals from the local clinics contributed 70% towards our CS rate in Q1 2024 and remained consistently ~80% on average, when compared with institutional audits from 2020 (80%) and 2023 (85%).

Conclusion. While measures were already in place to reduce rates of unnecessary CS at QNRH, the findings from our audit show that current strategies to reduce the CS rate will be unlikely to reach the target of 28% for public sector facilities, owing to our referral pattern and the drainage areas covered by this hospital. Despite the small sample size in this audit, evidence points towards the need for a district hospital in this subdistrict to help reduce our facility CS rate.