In the literature, various rates of cesarean section completion have been reported. In our series, cesarean section completion rates were 1.28%, 1.30%, 1.53%, 1.32% respectively in 2004, 2007, 2008, 2009. Our rate is significantly lower than the optimal range set by the World Health Organization (WHO) which is 10% - 15% [2]. In Mali, at the CHU Gabriel Touré de Bamako DIALLO C.H. [7] found 7.82% in 1989; CISSE H.G. [8] obtained 1.28% in 1988 in the same health structure. In 1996 at the hospital of Point “G” TEGUETE I. [9] found a rate of 24.05%. SANOGO M. [10] found 18.49% in 2004 and 28.03% in 2006 at the Reference Health Centre in Koutiala, at the same time DIABY M. [11] obtained 10.8% (January to June 2005) before free and 10.3% (July to December 2005) during the free. BERTHE Y. [12] recorded a rate of 18.6% in the obstetric gynecology department of the C.R.H. de Bouaké in Côte d'Ivoire. These rates are higher than those obtained during our study period. This is due to the completion of these caesarean sections in hospitals and reference health centres whose areas are larger than ours.

Socio-demographic characteristics: The average age was between 19 and 25 years. The frequency of caesarean section in this age group was 34.1% in 2007, 29.7% in 2008, 38.8% in 2009. Some authors found superior results than ours, KONATE M. [13] at the Gabriel Touré 82.1%, TEGUETE I. [9] at The Hospital of Point “G” 79.3%. On the other hand our rate is close to those reported by KOUYATE A.S. [14] which found 45.9% and SANOGO M. [10] which yielded 36.7% in Mali. It appears that the average ages corresponding to the peak of caesarean sections are those of the optimum reproductive period. In our study, we noted evacuations at 89.4% in 2007, 70.0% in 2008, 49.3% in 2009. These rates are close to those obtained by DIALLO C. H. [7] or 71.87%, TRAORE A. F. [15] or 91.9%; TEGUETE I. [9] or 49.35%.

With regard to reference/evacuations: The reference system experiencing functional failures, some of our patients were admitted directly. This predominance of evacuations found by most Malian authors is the work of a national health policy based on a referral/evacuation system with the aim of reducing maternal-neonatal morbidity. The average distance covered was 75.45 kilometers and the longest distance 150 km.

The majority of our participants received 1 to 3 antenatal consultations. We achieved a rate of 66.3% in 2007, respectively; 80.2% in 2008; 72.4% in 2009. In 2004, the frequency of parturients who received 1 to 3 antenatal visits was 52.8%. This rate is close to that obtained by DIABY M. [11] who found 52%. These results are explained by the presence of many community health centers in the Bougouni health area.

During the study period, we performed 211 caesareans for preeclampsia; 179 caesareans for acute fetal suffering; 86 caesareans for prolonged delivery labour. In the absence of radiopelvimetry, only the clinic allowed us to diagnose the different types of bone dystocies encountered, which are among other things: the basins generally narrowed with frequencies of 3.3%, 4.5%, 3.3%, 4.9% respectively in 2004, 2007, 2008, 2009 and immature basins with a rate of 6.7%, 0.0%, 0.3%, 4.5% in 2004, 2007, 2008 and 2009 systematically led to a caesarean section. The boundary pools (after the failure of the work test) represented a rate of 0.0%, 0.7%, 1.5% in 2007, 2008 and 2009. Our rate is significantly lower than that reported by CISSE B. [16] at the Kayes Reference Health Centre, SIDIBE Y [1] at the Koro Reference Health Centre with a rate of 24.76% respectively; 25.27%. These high rates of bone dystocies leading to caesarean section in these areas may be explained by: the high frequency of teen delivery associated with very frequent early marriages in these areas. Fetal appendix indications: during our study, retro-placental hematoma frequencies of 0.8%, 2.6%, 1.9% respectively were recorded. Our retro-placental hematoma rate of 4.3% in 2004 is lower than those obtained by some authors including SANOGO M. [10] 12.94% in 2006; TRAORE A. F. [15] 11.78% and CAMARA S. [17] 12%. Given the feasibility of ultrasound only on weekends, the precise diagnosis of third trimester haemorrhages is most often diagnosed in per operative procedure. We have no other explanation for this difference in outcome with ours. The placenta previa accounted for 7.6%, 5.3%, 9.9%, 5.6% respectively during the 2004 study period, 2007, 2008, 2009. Our different rates are higher than the rates of THIERNO M. [18] which found 2.5%; RACINET [19] rated 3% and CAMARA S. [17] who found 3.58%. On the other hand, they are lower than those of DIALLO C. H. [7]; TRAORE A. F. [15] and TEGUETE I. [9] who obtained 8.12% respectively; 8.68% and 9.03%. In our series, the frequency of cesarean section indications for fetal suffering was 15.7%; 13.8%, 20.5%, 18.7% respectively in 2004, 2007, 2008, 2009. Our rate is close to those obtained by TEGUETE I. [9] (16.06%); CISSE B. [16] (18%).

In the absence of electronic monitoring of the foetal heart, only the clinic allowed us to diagnose acute fetal suffering based on changes in the colour of the amniotic fluid and/or foetal heart rate to obstetrical stethoscope.

The indications of caesarean section related to the genital state: the bi-scarred uterus represented 4.3% in 2004; 2% in 2007; 6.3% in 2008; 7.5% in 2009. These rates are close to those obtained by SANOGO M. [10] and SIDIBE Y. [1] with 6.71% and 3.30% respectively. A doubly scarred uterus associated with any other risk factor for dystocia birth puts the old scar at risk of disunity. To avoid this tragedy, the obstetrician resorts to caesarean section, hence the increase in his rate among the indications of this intervention. We noted 16 cases of uterine rupture at a frequency of 7.6% and 8.9%, 9.9%, 9.7% respectively in 2004, 2007, 2008, 2009. These rates are higher than those obtained by TRAORE Y. [20] in 2008 and are close to that of SANOGO M. [10] during the second half of 2005 with a frequency of 6.3%; 08%. On the other hand, SIDIBE Y. [1] found in 2004 a higher rate than ours with a frequency of 12.7%. Several factors come into play for the occurrence of these extreme emergencies. As the various outlying health areas are too far from the reference health centre, the deplorable state of the roads, especially during the rainy season, has been blamed in the prolonged period of evacuations of these parturients. The insufficient number of ambulances to transport them, the insufficient training of some health workers to detect emergencies also lead to a delay in the decision to evacuate. The clandestine and abusive use of oxytocins and often even the husband's refusal to accept the reference decision immediately are among other causes of uterine rupture. Other caesarean section indications were shoulder presentations, cord providence, providences of the limbs; loaded obstetric history, genital prolapse. During the study period, the rates found in our study are lower than that found by SIDIBE Y. [1] with a rate of 59.3%. Some indications of caesarean section dependent on the expectation of the obstetrician may explain this difference in rate with ours.

Per operatively associated gestures: Our study reports rates of tubal resection ligation ranging from 0.4% - 7.1% depending on the years to 1.3% - 1.9% hysterectomy in the context of laparotomy for uterine rupture. Our rates of tubal ligation and resection and hysterectomy are significantly lower than those obtained by TRAORE Y. [20] and SANOGO M. [10] with rates of 28.57% and 7.1% respectively; 85.71% and 14.28%. In carrying out these gestures, many parameters must be taken into account: anatomical lesions, the general condition of the patient, his age, his parity, his level of education, his desire to procreate, the experience of the anaesthetist and that of the surgeon.

In terms of maternal-fetal prognosis: The surgical consequences were simple in 90% of our patients. However, infectious complications of endometritis and parietal suppurations were noted. Thus in 2004, the rate of endometritis was 2.90% and that of parietal suppuration was 9%, whereas in 2009 the rate of endometritis was 1.5% and that of parietal suppuration was 7.1%. Our parietal suppuration rate is higher than those found by SIDIBE Y. [1] and SANOGO M. [10] with a rate of 5.49% and 2.99% respectively. We noted maternal deaths with a rate of 2.4%, 2.4%, 4.3%, 0.4% respectively in 2004, 2007, 2008, 2009. The rates for 2007, 2008 are higher than those obtained by SANOGO M. [10], SIDIBE Y. [1] and DIABY M. [11] at a rate of 1.49%; 1.10% and 1.10%.

We are seeing a gradual decrease in the maternal death rate in 2009. This decrease is statistically significant [Table 8, P—0.03]. These deaths are mainly due to hemorrhages in the third trimester of pregnancy.

And stillbirth rates were 17.6%, 22.4%, 27.4%, 21.7% respectively in 2004, 2007, 2008, 2009; we are also seeing an increase in the number of newborns alive. However, the neonatal death rate remained flat (Table 8).

The delay in making evacuation decisions, the delay in the care of patients, the long time to transport these patients to the reference health centre because of the condition of the journey, the surgical team being composed of a single anaesthetist and a block assistant, the lack of paediatric service for the resuscitation of newborns are considered factors that can hinder the good prognosis of this intervention at the reference health center of Bougouni despite the institution of the free. For caesarean kits: in 1 case/100 the caesarean kit was not available at the time of the caesarean section. This rupture of the caesarean kits delays management with adverse consequences for the mother and fetus.

Length of hospitalization: The average length of hospitalization was 10 days with extremes of 5 to 25 days. Our study noted that there is a statistically significant relationship between length of hospitalization and free caesarean section [Table 7, P—0.01]. This value is close to those obtained by SYLLA C. [21] at C H U Gabriel TOURE in 2004 and SIDIBE Y. [1] at the Koro Reference Health Centre with an average duration of 11 days each. In the absence of post-operative complications, the average length of hospitalization should not exceed 10 days.

Difficulties free caesarean section: The free caesarean section has improved the maternal-fetal prognosis. However, some difficulties hinder its smooth running, including: the difficulty of communication in areas not covered by a mobile telephone network requiring the technical directors of the centres to travel miles in order to reach the reference health centre, the weak community organization to support village participants in access to community health centres or referral health centres, the organisation of the referral/evacuation system to enable the rapid management of obstetrical emergencies, the late use of parturients to care facilities resulting in a high rate of deaths born, the delay in obtaining adequate care at the level of referral structures during on-call hours.