Improving the quality of obstetric care is an urgent priority in low income countries, where maternal and perinatal morbidity and mortality remain high. Clinical audit is a tool to improve quality of care. Specifically clinical audit in MNCH is a tool to reduce maternal and perinatal morbidity and mortality. Cesarean section is among "five auditable'' MNCH scenarios according 2012 women lung foundation. This study is a one year retrospective cross-sectional study among 99 women who delivered by cesarean section from July 2016-June 2017 in Mearg general hospital in West Tigray, Ethiopia. The aim of this survey was to investigate cesarean section rate (CSR) and indications of cesarean section to improve quality of obstetric care by reducing unnecessary cesarean sections. In the study period 99 women delivered by cesarean section among 749 institutional deliveries which gives an institutional cesarean section rate of 13.2%. Medical records were retrieved for 81 mothers. The most common indications for cesarean section were cephalopelvic disproportion (CPD) in 19 women (23.5%), antepartum hemorrhage in 11 (13.6%) and obstructed labor in 10 (12.3%). Majority of the cesarean sections 75(88.9%) were done under spinal anesthesia. Seven (8.6%) mothers had no justified indication for cesarean section according to criteria based audit. From the total 99 cesarean sections there was one (1.0%) maternal death. There was significant number of cesarean sections done with medically unjustified indications but comparatively low with the country and global figure. The three common indications for CS in this study were CPD, APH, and obstructed labor. A huge percentage of lost medical files was observed. Keeping medical records is the safest, simplest and cheapest way to analyze cesarean section indications, to reduce unjustified/unnecessary cesarean sections.