Background Medical doctors with postgraduate training in Global Health and Tropical Medicine (MDGHTM) from the Netherlands, a high-income country with a relatively low caesarean section rate, assist associate clinicians in low-income countries regarding decision-making during labour. Objective of this study was to assess impact of the presence of MDGHTMs in a rural Malawian hospital on caesarean section rate and indications. Methods This retrospective pre- and post-implementation study was conducted in a rural hospital in Malawi, where MDGHTMs were employed from April 2015. Indications for caesarean section were audited against national protocols and defined as supported or unsupported by these protocols. Caesarean section rates and numbers of unsupported indications for the years 2015 and 2016 per quarter for different staff cadres were assessed by linear regression. Results Six hundred forty-five women gave birth by caesarean section in the study period. The caesarean rate dropped from 20.1 to 12.8% (p < 0.05, R2 = 0.53, y = − 0.0086x + 0.2295). Overall 132 of 501 (26.3%) auditable indications were not supported by documentation in medical records. The proportion of unsupported indications dropped significantly over time from 47.0 to 4.4% (p < 0.01, R2 = 0.71, y = − 0.0481x + 0.4759). Stratified analysis for associate clinicians only (excluding caesarean sections performed by medical doctors) showed a similar decrease from 48.3 to 6.5% (p < 0.05, R2 = 0.55, y = − 0.0442x + 0.4805). Conclusions Our results indicate that presence of MDGHTMs was accompanied by considerable decreases in caesarean section rate and proportion of unsupported indications for caesarean section in this facility. Their presence is likely to have influenced decision-making by associate clinicians.

Objective Prolonged second stage of labour potentially leads to maternal and perinatal complications. Options for clinical management are augmentation with oxytocin, instrumental vaginal birth or second-stage caesarean section. We aimed to describe incidence, management and outcome of prolonged second stage of labour in a low-resource setting in Malawi. Methods Retrospective analysis of medical records and partographs of all women who gave birth in 2015-2016 in a rural mission hospital in Malawi, comparing labour tracings with management protocols. Primary outcomes were incidence of prolonged second stage, instrumental vaginal birth and caesarean section. Furthermore, management and outcomes were assessed. Women arriving in hospital in the second stage of labour were compared to women arriving in an earlier stage of labour. Results Of all 3,426 women giving birth in the study period, 307 (9.0%) were diagnosed with prolonged second stage, based on their partographs. Of these women, 22 (7.2%) had labour augmented with oxytocin, 31 (10.1%) gave birth by vacuum extraction and 64 (20.9%) by caesarean section. Spontaneous vaginal birth occurred in 212 (69.0%). In total, 566/3,426 (16.5%) women were admitted whilst already in the second stage of labour of whom 538/566 (95.1%) had spontaneous vaginal births and 38/566 (6.7%) ended up having prolonged second stage registered in their partographs. Conclusion Prolonged second stage of labour is relatively common in this hospital, although diagnosis may be hampered by a very sizeable proportion of women arriving whilst already in the second stage, although a large majority of these women gave birth spontaneously. Caesarean section occurred twice as often as vacuum extraction, suggesting a role for additional training and decision-making during childbirth to support the use of vacuum extraction.