Caesarean section rate as a process indicator of safe motherhood programmes: the case of Midlands Province.

OBJECTIVE To evaluate the Safe Motherhood Programme of Midlands Province by means of process indicators, in particular Caesarean Section Rates (CSR), in comparison with the commonly used outcome indicator Maternal Mortality Ratio (MMR). DESIGN A cross sectional descriptive study. SETTING Midlands Province, Zimbabwe. MAIN OUTCOME MEASURES Process indicators of the Safe Motherhood Programme of Midlands Province, and Maternal Mortality Ratio as an outcome indicator for the nation and the province. RESULTS For Midlands province, a population based CSR of 3.1% was calculated for 1999, which is well below the internationally recommended 5%. The figures for the eight districts ranged considerably from 0.18 to 7.1%. The provincial institutional CSR for the same year was 8.7% (range: 0.53 to 34.5) with a significantly higher rate in private institutions (24%) as compared to government run hospitals (8%), (Chi-square 398.26, p << 0.05). The Ante Natal Care (ANC) coverage ranged from 43.9 to 75.4% with a provincial average of 62.8%. The provincial institutional delivery coverage figure was 55% (range: 49.9 to 63.6%). These findings differed from the figures obtained in the Demographic and Health Survey for the same year: ANC and institutional delivery coverages for the Midlands province were 95.2% and 73% respectively. The availability of obstetric services was well above the minimum acceptable level as defined by the World Health Organisation (WHO) guidelines. CONCLUSION MMR is not a very useful indicator to monitor progress in Safe Motherhood Programmes. The figures are unreliable, difficult to obtain if population based, and they show a wide range, even within one given year. Process indicators, especially CSR are easily accessible and give insight in the degree of unmet obstetric need and in referral patterns within one district and the province.