Introduction: the WHO has identified an ideal caesarean section rate for a nation of 10-15%, but much higher rates are seen in tertiary referral centres in resource-poor countries. Interventions by the author to improve care and reduced unnecessary caesareans were undertaken including staff education and production of clinical guidelines. This study aimed to identify indications for caesareans and whether the decision to perform caesareans was appropriate in order to improve care, and whether the above interventions had an impact on this process.

Methods: two groups of 100 consecutive cases from October 2014 and 100 from February 2015 were retrospectively selected that resulted in caesarean. These case notes were analysed for demographic data, caesarean indication and appropriateness.

Results: in 46% of cases the decision for caesarean was considered appropriate. No significant difference (p>0.05) was found between the two groups in terms of patient demographics or appropriateness of caesarean (43% in Oct-14 compared to 48% in Feb-15). The most common group of indications for caesarean was dystocia (43.5%) with 28% appropriate; followed by fetal distress (18.5%) with 30% appropriate; previous scar (17%) with 85% appropriate; malpresentation (10.5%) with 48% appropriate; and maternal compromise (10%) with 80% appropriate.

Conclusion: the high number of unnecessary caesareans appeared to be related to lack of knowledge and inexperience of staff. Despite attempts to address this through teaching the scope of the problem is so large it needs a fundamental change in the healthcare system in terms of resources, education, continuing professional development and clinical governance.