**3. Optimizing the use of caesarean section**

To rationalize the use of this major procedure in obstetrics practice, individual providers, professional associations, facilities, and health-care systems should seek a path beyond TLTL and TMTS, which means reducing unnecessary CS while ensuring the availability of caesarean birth for women who required it [4]. However, the challenge is to keep CS rates low while maintaining safe outcomes for the mother and infant. This requires continuous auditing of CS and increasing adherence to guidelines [4, 42].

For such endeavor identifying the clinical and non-clinical factors contributing to caesarean birth and the appropriate consideration of risks and alternatives used in the decision to undertake a CS is an important activity. This is supported by evidence that indicates the main reasons for performing a CS were clinical factors and the doctor's role in decision making [43]. Other non-clinical factors may also contribute, though these are more challenging to identify. For example, studies conducted to evaluate the appropriateness of decisions made for CS in Tehran and Uganda hospitals showed that more than half of CS performed was considered inappropriate with a significant difference between public and private hospitals. Conducting clinical audit would examine in more detail the clinical conditions for which they need for CS is questionable or inappropriate [39, 44, 45].

Therefore, auditing the clinical factors related to the use of CS is strongly recommended in all hospitals to reduce unnecessary interventions, to improve decision-making and consistency of practice among care providers particularly in resource-limited countries [43]. These in turn will increase adherence to guidelines and protocols in using the procedure, and to enable the development of guidelines or protocols that consider the difference of contextual factors [4]. Even though, global organizations are creating guidelines for interventions to reduce caesarean section rates evidence is insufficient for most strategies [4, 46]. More research is urgently needed on interventions for reducing unnecessary caesarean section and increasing vaginal birth after caesarean section rates [4].

Vaginal Birth After Cesarean Section (VBAC) is another mechanism of reducing CS rates since a repeat CS after caesarean birth is the major contributor to rising trends of CS rate globally [47]. However, limited numbers of mothers with a previous CS are allowed to attempt VBAC and factors behind this and its success was not well-understood [18]. Furthermore, perinatal outcomes of children born by caesarean section in LMIC are not known and the risks of maternal death after caesarean section in countries with low and high rates of the procedure are not known. Unless the key risk factors for complications in women undergoing caesarean section are known, it is difficult to target efforts to improve pregnancy outcomes [11, 48, 49]. In Ethiopia little information is locally available regarding outcomes between vaginal, VBAC and CS birth, and most of these studies provide limited evidence on maternal and perinatal outcomes occurred before hospital discharge and use secondary data which suffers from incompleteness and unreliable information [50].

The difficulty with monitoring and comparing CS rates, as well as planning or instituting interventions to modify CS rates, requires information about the

*Magnitude, Factors Associated with Cesarean Delivery and Its Appropriateness DOI: http://dx.doi.org/10.5772/intechopen.98286*

indications for CS and the appropriateness of surgical birth. A major part of the problem is that there is no agreed-upon international standard of classification of indications for CS. After conducting several systematic reviews, the WHO concluded that the Robson classification as a global standard tool for international use which is important to know which groups of women are mainly contributing to the increase in CS rate [51]. The Robson classification also called the Ten Group Classification System (TGCS), classifies women into 10 mutually exclusive and exhaustive groups based on the category of the pregnancy, the previous obstetric record of the woman, the course of labour and delivery, and the gestational age of the pregnancy [6]. Multiple studies have examined rising CS rates in high and middle-income countries using the Robson classification system, though few studies involving low-income countries have been conducted [52–56]. In Ethiopia only one study has been conducted using Robson classification among women who underwent CS. The study was limited to one public hospital site which excludes the influences of private obstetric care [29]. Therefore, a prospective study involving both women receiving both public and private hospital care is recommended to understand the proportion of CS within each Robson group. Furthermore, as TGCS is not an audit of the appropriateness of indications for CS, further research is required to assess the suitability of the clinical indications [29]. Whilst small number of studies have reported maternal and perinatal outcomes in Ethiopia [31, 32, 50] no previous research has explored the institutional and decision making factors influencing CS use despite a high rate of post-CS mortality and morbidity.
