• N Morisaki, T Ganchimeg, E Ota, J P Vogel, J P Souza, R Mori, A M Gülmezoglu, and WHO Multicountry Survey on Maternal and Newborn Health Research Network.
• Department of Health Policy, National Center for Child Health and Development, Tokyo, Japan; Department of Paediatrics, Graduate School of Medicine, University of Tokyo, Tokyo, Japan.
• BJOG. 2014 Mar 1;121 Suppl 1:66-75.

ObjectiveTo illustrate the variability in the use of antibiotic prophylaxis for caesarean section, and its effect on the prevention of postoperative infections.DesignSecondary analysis of a cross-sectional study.SettingTwenty-nine countries participating in the World Health Organization Multicountry Survey on Maternal and Newborn Health.PopulationThree hundred and fifty-nine health facilities with the capacity to perform caesarean section.MethodsDescriptive analysis and effect estimates using multilevel logistic regression.Main Outcome MeasuresCoverage of antibiotic prophylaxis for caesarean section.ResultsA total of 89 121 caesarean sections were performed in 332 of the 359 facilities included in the survey; 87% under prophylactic antibiotic coverage. Thirty five facilities provided 0-49% coverage and 77 facilities provided 50-89% coverage. Institutional coverage of prophylactic antibiotics varied greatly within most countries, and was related to guideline use and the practice of clinical audits, but not to the size, location of the institution or development index of the country. Mothers with complications, such as HIV infection, anaemia, or pre-eclampsia/eclampsia, were more likely to receive antibiotic prophylaxis. At the same time, mothers undergoing caesarean birth prior to labour and those with indication for scheduled deliveries were also more likely to receive antibiotic prophylaxis, despite their lower risk of infection, compared with mothers undergoing emergency caesarean section.ConclusionsCoverage of antibiotic prophylaxis for caesarean birth may be related to the perception of the importance of guidelines and clinical audits in the facility. There may also be a tendency to use antibiotics when caesarean section has been scheduled and antibiotic prophylaxis is already included in the routine clinical protocol. This study may act as a signal to re-evaluate institutional practices as a way to identify areas where improvement is possible.© 2014 RCOG The World Health Organization retains copyright and all other rights in the manuscript of this article as submitted for publication.

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