Caesarean section (CS) an obstetric surgery, is one of the important signal functions of comprehensive emergency obstetric care (CEmONC). Although rates are globally rising, they are still hugely inaccessible in most underserved rural areas in sub-Saharan Africa [1] . According to Tanzania Demographic Health Survey in 2016 the caesarean section rates in Tanzania is estimated to be 6% with 9.6% in urban and 3.2% in rural areas, where 69% of the population live [2] .

Despite being safe, caesarean section deliveries may present with difficulties for the clinician, particularly in low-resource. Most CS done in Lower and Middle Income Countries are performed in settings that do not meet minimum safety and quality standards, increasing complications and morbidities from the procedure [3] [4] . The maternal complications include hemorrhage, blood transfusions, wound infections, caesarean hysterectomies, injury to adjacent organs and maternal death [5] - [10] . On the other hand, caesarean section deliveries especially those done as emergency are connected to iatrogenic premature deliveries of newborns and hence infancy-related respiratory distress, admissions to neonatal intensive care unit, low Apgar scores at birth and longer hospitalization [7] [11] - [14] .

The majority of Tanzanians enter into healthcare system through primary health care facilities i.e., dispensaries, health centres (HC), and district hospitals (DH) [15] . The Tanzania National Road Map Strategic Plan for Acceleration of Reduction of Maternal and Child Deaths (One Plan II) established a goal of 100% CEmONC capacity for hospitals and 50% for health centres by 2015 in order to expand access to these services. However, by 2015 only 22.2% of all health centres were providing CEmONC services [16] . Therefore, between August 2015 and August 2019, the Tanzanian Government renovated and constructed 350 health centres and 69 district hospitals to provide CEmONC services [17] .

Little information is available regarding maternal and fetal outcomes of CS delivery in primary health care facilities. Therefore, this study aims to determine the common indications as well as the immediate maternal and fetal outcomes after caesarean section surgery performed at this level.

A total of 782 caesarean sections performed during the period of 1^st January to 31^st December 2020 were included, 679 from district hospital and 103 from health centres. 72 files were missing all from the district hospital ( Figure 1 ).

The median age of study participants was 24 years in health centres and 26 years in district hospital. About 16.5% of operated pregnant women at health centres had age below 20 years as compared to 9.4% in district hospital. Most of women had primary education, parity of 1 - 4 and gestation between 37 - 42 weeks. Regarding the type 89.1% were emergency CS, general anasthesia (ketamine) was used in 99.4% of cases and only 5.6% of cases received preoperative antibiotics ( Table 1 ).

The common indications for CS were obstructed labour (29.0%), previous scar (19.9%) and cephalopelvic disproportion (17.0%). There were more obstructed labor in health centres (44.6%). Trial of scar were done at district hospital and all with pre-eclampsia/eclampsia, bad obstetric history were referred from to district hospital ( Table 2 ).

Most of the women who underwent caesarean section had no post-operative complications. Of those with complications, the common ones at health centres and district hospital respectively were excessive blood loss 5.8% and 5.7%, blood transfusion 3.9% and 6.5%, hospital stay more than 3 days 1.0% and 2.4% and infection 1.9% and 1.2%. There was no statistical significance difference in immediate maternal outcomes between health centres and distric hospital ( Table 3 ).

The common immediate fetal outcomes at health centres and district hospital respectively were term babies 93.7% and 87.9%, alive 96.4% and 95.3% with Apgar score at 5 minutes were ≥7 (95.3%) and (98.4%) majority weighed ≥ 2500 grams (96.4%) and (91.8%). There was no statistically significant difference in immediate fetal outcomes between health centres and district hospital ( Table 4 ).

In this study, a total of 782 caesarean sections were assessed. The findings show the commonest indications were obstructed labour, previous scar(s) and fetal distress. Obstructed labor indications were more at health centres whereas previous scar(s) indications were more at the district hospital. Majority of women had no post- operative complications, however of those few with complications, the commonest were post-partum hemorrhage, blood transfusion, infection and prolonged hospital stay more than three days. On the other hand, most of babies were born alive, at term with Apgar score equal or more than 7 at 5 min and body weight more than 2500 g. Furthermore, there was low utilization of spinal anesthesia. There were no statistical significant difference in immediate outcomes of caesarean section.

In this study, the increased obstructed labour as indication for caesarean section in especially at health centres could be due to increased proportion of pregnant women below 20 years than thatin Tanzania Demographic Health Survey in 2016 [2] . This was similar to the study done at district hospital in southern Tanzania. The results were higher compared to the study done in public hospitals in Bangladesh and Muhimbili National Hospital in Tanzania [18] - [20] . This could be due to the difference in the levels of the facilities with higher facilities receiving more complex cases as referrals. Previous scar(s) as indication for CS was more at the district hospital, probably because of referrals from the lower facilities for women with previous scar. In Tanzania, women with previous scar are recommended to deliver in hospitals. The results were comparable to study done in Goma, DR Congo [21] , but contrary to higher referral facilities such as Muhimbili National Hospital in Tanzania and another tertiary hospital in Pakistan [19] [22] . The findings also show more women had undergone caesarean section due to malpresentation at health centres compared to district hospital, therefore there is a need to evaluate these differences in indications.

Most of the women who underwent CS had no post-operative complications. As in other studies in India and Nigeria, postpartum hemorrhage complicates the most caesarean section procedure [5] [23] . However, the findings were lower compared to the study done at Iringa Regional Referral Hospital in Tanzania [7] . The difference in levels of facility can explain this, the regional hospital handles more complicated cases. The proportion of post-partum hemorrhage in this study seems to be similar between upgraded health centres and district hospital despite the fact more women had the primary surgeries at health centres compared to district hospital, experience of surgeons can explain this finding with district hospital having more experienced surgeons than the health centres. Post-partum hemorrhage also reflects on the increased transfusion rates in our study. However, few patients had received transfusion at health centres due to inadequate blood products health centres, This resulted to about three of patients to be referred district hospital for blood transfusion after surgery.

We observed the other immediate maternal outcomes were comparable between health centres and district hospital as in postpartum complication discussed above. Wound site infection proportions were lower compared to tertiary hospital in Mwanza, Tanzania [24] [25] . The study findings also show lower wound dehiscence; however, these were contradicting findings as majority of women didn’t receive pre-operative antibiotics in all facilities but all received antibiotics post operatively. WHO guidelines recommends prophylactic antibiotics for women undergoing elective or emergency caesarean section 30 - 60 minutes before skin incision [26] . The higher proportions of surgical sites were found in a prospective study done in rural settings in Rwanda however, the follow-up was 30 days after surgery [11] . Furthermore, the maternal deaths were lower compared to other studies; a study done Muhimbili National Hospital, a tertiary hospital in Tanzania, however the study was done among women with previous caesarean delivery and also load of high risk patients at this tertiary hospital is the issue of concern [10] . Another study was done at a district hospital in Nigeria but the hospital had no obstetric unit [11] .

On the other hand, more preterm babies were delivered at district hospital due to the fact high risk pregnancies were referred to deliver at district hospital. However, in general the neonatal outcomes were relatively good in both facilities. The result at district hospital were similar to the study done at a referral hospital in northern-eastern Tanzania and in rural Bangladesh [18] [27] . The findings were also similar to a national review of caesarean section deliveries done in Brazil, however, in this review the multiple births were excluded [13] . There were more low birth weight deliveries at district hospital due to above reasons. This finding at district hospital corresponds with studies done at Muhimbili National Hospital in Tanzania, Democratic Republic of Congo and Iran [14] [28] [29] . Therefore, there is a need to strengthen more care for preterm and low-birth-weight among babies delivered at primary health facilities level including Kangaroo mother care

Moreover, most of babies delivered both at health centres and district hospital had Apgar scores equal or more than 7 at 5 minutes. This was despite the fact that fetal distress was the third common indication for CS; thus, this probably because of timely intervention of fetal distress. However, more low Apgar scores at health centres perhaps because there was more obstructed labour than the district hospital, more training on helping babies’ breath and neonatal resuscitation should be considered at the health centres. The results in district hospital are comparable to a study done in Nepal in 2020 [30] . More low Apgar score was found other studies done in regional hospital in southern Tanzania and Ethiopia, however these were referral hospital receiving more complicated patients [7] [12] . Furthermore, stillbirths were low, the results were similar to the study done in India [31] . The lower incidence of stillbirths was in study done in Bangladesh however this was a population based study [32] .

This study had some limitations, there some missing files due to poor record keeping; short time of observation and the study was done at rural settings it cannot be generalized to facilities in urban settings and higher level facilities. Lastly the long-term complications were not assessed. Despite limitations encountered, this is important study as it provides necessary information on the performance of primary health facilities providing caesarean section services.

The results from the study show that obstructed labour was the commonest indication for caesarean section at primary health facilities. There was no difference in immediate maternal and fetal outcomes of caesarean section between the district hospital and the upgraded health centres. Clinical audits of indications for caesarean section and prospective studies for late maternal and fetal outcomes of caesarean section performed at primary health facilities to be conducted.

We acknowledge all members of the academic staff in the Department of Obstetrics and Gynaecology at Muhimbili University of Health and Allied Sciences and Muhimbili National Hospital for their valuable contributions. Also we acknowledge the District Executive Director at Lushoto District Council for the support during the study.

This study received financial support from the Ministry of Health in Tanzania.