Prevalence and predictors of caesarean deliveries at the Tamale teaching hospital in Northern Ghana

Abstract

Background

Modern medicine has significantly transformed the process of childbirth among women. The preferred mode of childbirth has become of global interest to many researchers due to the steady rise in recent caesarean section (CS) rates. While CS is often viewed as a life-saving intervention, it is associated with both immediate and long-term complications for the mother, newborn, and future pregnancies. To better understand the medical and non-medical reasons for CS among women, this study was conducted to identify the socio-demographic and obstetric factors that influence CS in the Tamale Metropolis.

Methodology

A retrospective cross-sectional study was conducted among 318 postpartum mothers at the Tamale Teaching Hospital. Descriptive analysis, univariate logistic regression and stepwise multivariate logistic regression model were conducted, with a p-value < 0.05 considered statistically significant.

Results

The majority of respondents (63.5%) were below 30 years. Almost all respondents (95.3%) were enrolled in the National Health Insurance Scheme (NHIS). The majority (95.91%) had single births. Most respondents (91.2%) had spontaneous vaginal delivery. The prevalence of CS was 8.8%. Significant factors influencing the preference for CS were maternal age above 30 years (aOR = 2.27, 95% CI = 1.01–5.12), rural settlement (aOR = 0.31, 95% CI = 0.10–0.92), twin delivery (aOR = 6.88, 95% CI = 1.64–28.95), and obstetric complication (aOR = 10.55, 95% CI = 2.42–46.04).

Conclusion

There is a need to focus on initiatives that address regional disparities, enhance access to comprehensive maternal healthcare services, and promote informed decision-making regarding mode of delivery to ultimately improve maternal and infant health outcomes.

Background

Advances in modern medicine have transformed childbirth, with three primary delivery methods: spontaneous vaginal birth, assisted vaginal birth, and Caesarean section (CS) [9, 12]. CS is a surgical procedure indicated when vaginal delivery poses clinical risks such as placenta previa, cephalopelvic disproportion, fetal distress, prolonged labor, or multiple gestations [22]. It may also be performed based on maternal request or psychological factors after counseling [24]. However, CS carries short- and long-term risks including bleeding, infection, thromboembolism, uterine scarring, and complications in future pregnancies like placenta previa and uterine rupture [16]. Therefore, CS decisions should be clinically justified and personalized.

Globally, CS rates have risen considerably since 1990, with notable increases in regions such as Eastern Asia and Northern Africa, while sub-Saharan Africa has experienced modest growth [7]. The global CS rate currently stands at 21.1%, projected to rise to 28.5% by 2030 [7]. Factors influencing CS rates vary by region and include health policies, cultural norms, healthcare quality, and women’s preferences [17, 27]. The WHO advises against fixed CS rate targets, recommending instead individualized maternal care based on clinical needs [24].

In sub-Saharan Africa, CS prevalence ranges widely between public and private health facilities, with clinical indications like obstructed labor and fetal distress being primary reasons for CS [23, 27]. In Ghana, although most women prefer vaginal delivery, approximately 55% of CS procedures are elective, indicating influence from non-emergency factors such as maternal request or provider recommendation [13]. CS rates in Ghana vary from 14.6% to 26.9%, with higher rates in private compared to public facilities [4, 13, 14, 19]. The high caesarean section (CS) rate in Ghana is concerning due to its links with not only adverse foetal outcomes but also increased maternal morbidity and mortality, particularly in repeat procedures [19, 24]. CS prevalence is notably higher in private facilities—for example, 40.6% in a Ghanaian private hospital versus 14.6% in a public one—likely driven by factors such as financial incentives, patient preference, and more lenient clinical thresholds [13, 14, 27].

Socio-demographic, economic, and obstetric factors significantly predict CS deliveries in Ghana, including maternal age, parity, education, wealth, gestational age, antenatal visits, birth weight, and previous pregnancy loss [4, 6, 13]. However, there is limited data on CS prevalence and predictors in the Tamale metropolitan area.

This study aims to fill this gap by examining the prevalence and determinants of CS in Tamale Metropolis, contributing to evidence-based strategies for maternal healthcare improvement. Findings will support local health planning, policy formulation, and targeted training to promote safe, equitable childbirth interventions. Further research is needed on long-term maternal and infant outcomes following CS in resource-constrained settings like Tamale.

Methodology

Study design, area, period and population

The study was conducted at Tamale Teaching Hospital (TTH) in the Northern Region of Ghana. TTH is the primary referral hospital in the five Northern regions of the country and was established in 1974. The hospital has a bed capacity of around 800 and provides specialist services in various fields, including obstetrics and gynaecology, surgery, orthopaedics and trauma, internal medicine, child health, pathology, ear, nose and throat, opthalmology, endoscopy, neurosurgery, anaesthesia and intensive care, psychiatry, dentistry, pharmacy, laboratory, and outpatient department. On the average, the hospital conducts about 8,000 deliveries annually. In this retrospective cross-sectional study, the birth records of all women who delivered live babies at TTH between October and December 2021 were reviewed.

Study variables

Outcome variable

The dependent variable was caesarean delivery. Delivery was dichotomised into “Spontaneous vaginal delivery” when mother delivered through the vagina and “caesarean delivery” when mother delivered through caesarean section. Birth records that documented all the types of caesarean delivery (planned/elective and emergency) were included.

Dependent variable

The main predictors included obstetric characteristics such as type of birth (singleton or multiple), gravidity, parity, gestational age, number of pregnancies in the last five years, previous history of low birth weight (LBW), abortion, stillbirth, and any obstetric complications. Additional predictors included family history of hypertension and the use of long-lasting insecticidal nets (LLINs), which were included due to their relevance to maternal health status. Low birth weight (LBW) is defined as a birth weight of less than 2,500 g (2.5 kg) at birth [25]. Sulfadoxine-Pyrimethamine (SP) doses were categorized as standard and non-standard: the standard dose involves two doses of SP administered during the second and third trimesters for intermittent preventive treatment of malaria, while non-standard doses refer to deviations from this regimen, such as fewer or more doses or doses given outside the recommended timing. In terms of antenatal care (ANC), timely ANC visits were defined as the first visit occurring before 16 weeks of gestation [26], while delayed ANC visits referred to the first visit occurring after 16 weeks. Furthermore, recommended ANC visits referred the mother who had at least four ANC visits, as per the World Health Organization (WHO) guidelines [26], with any fewer visits categorized as not recommended. Additionally, maternal conditions such as Hepatitis B, hypertension, anemia, sickling status, HIV, malaria, and other infections or conditions were also considered. Hypertension was classified as absent when blood pressure was ≤ 120/80 mmHg and present when blood pressure was ≥ 140/90 mmHg, while anemia was defined as a haemoglobin level of < 11.0 g/dl, with normal levels being ≥ 11.0 g/dl. These factors were critical in understanding the predictors of maternal and pregnancy outcomes in the study population.

Data on maternal conditions were extracted from routine tests conducted on pregnant women during their antenatal care visits. Maternal conditions, including Hepatitis B, pre-eclampsia, hypertension during antenatal care, haemoglobin levels at registration and 36 weeks, sickling status, HIV status, malaria infection during pregnancy, syphilis infection during pregnancy, and hypertension prior to pregnancy, were documented and monitored throughout the course of antenatal care.

Inclusion

The study included birth records of mothers who delivered live babies after the gestational age of viability (≥ 28 weeks) at Tamale Teaching Hospital between October and December 2021. As a retrospective cross-sectional study, data were extracted from hospital records. Therefore, direct consent from the mothers was not sought; however, ethical clearance and institutional permission were obtained to ensure the use of anonymized patient data for research purposes.

Exclusion criteria

Mothers who underwent laparotomy for extra-uterine pregnancy and those who had non-live births following caesarean section were excluded from this study. This criterion was applied to focus on the outcomes of live births, which are the primary interest of this study in examining maternal and neonatal health outcomes following caesarean section. Non-live births, such as stillbirths or other pregnancy losses, were excluded as they could introduce additional confounding factors that are outside the scope of this study’s objective of assessing maternal health outcomes and delivery mode preferences in live birth deliveries.

Data extraction and sample size

A pretested data extraction sheet was used to obtain information on maternal demographics, obstetric history, ANC attendance, delivery details, and neonatal outcomes. Additionally, to complement missing or incomplete information in the hospital records, particularly on socio-demographic characteristics and maternal preferences, follow-up interviews were conducted with a subset of mothers at their homes in Tamale township.

Trained research assistants, basically midwives, were oriented on the eligibility criteria for inclusion in the study and the data extraction process. Data collection was supervised daily to ensure consistency, completeness, and accuracy of the extracted data. During the study period, a total of 598 live births were recorded. However, 36 records were excluded due to laparotomies for extra-uterine pregnancies and incomplete birth records. As a result, 318 cases were included in the final analysis, representing approximately 56.2% of all live births during the study period.

Data management and analysis

Before data entry, data extraction sheets and semi-structued questionnaires were subjected to accuracy checks. The Kobo Collect app was used for data entry, and the data was exported to STATA version 17 for analysis. Descriptive statistics were used to calculate frequencies and percentages were reported for categorical variables. For continuous variables, means and standard deviations were determined. To determine the mother’s economic status, various socioeconomic indicator variables were considered, such as the mother’s and father’s profession and education, type of housing, water supply, presence of an indoor kitchen, electricity, indoor toilet, fridge, car, motorcycle, bicycle, and membership in health insurance.

All socioeconomic information was self-reported by the mothers, and no direct observations were made during the interviews. Principal component analysis (PCA) was used on the relevant socioeconomic indicator variables that contributed to a combined socioeconomic status score factor of more than 10%. The SES of each household was described using the first principal component (i.e., the component with the highest eigenvalue), which reflects the greatest variation in asset ownership (wealth index). The factor scores generated were then divided into terciles to classify households into the following categories: 33% of households were classified as low, and the highest 33% were classified as having high socioeconomic status.

Univariate logistic regression analysis was used to identify associations between variables and Caesarean section (Model I), followed by a stepwise multivariate logistic regression model (Model II) that considered variables that were significant in the univariate logistic regression. The goodness of fit of Model II was examined using the likelihood ratio test by comparing the likelihood of the data under the full and alternative models. If the overall model recorded a p-value less than 0.05, the model was considered good. The variable inflation factor (VIF) was used to cater to multicollinearity, and explanatory variables with VIF values exceeding 5 were excluded from Model II. Adjusted odds ratios and confidence intervals were computed with p values < 0.05 and were considered statistically significant in Model II.

Ethical considerations

Ethical approval for this study was obtained from the Department of Research and Development, Tamale Teaching Hospital. The ethical clearance number for this study is TTH/R&D/SR/152. Informed consent was obtained from the respondents before conducting the interviews. The data obtained from the study was kept confidential, and personal information was anonymised during the data collection, analysis, and dissemination of findings. Identification codes were used for data management, storage, analysis, and reporting. A file containing information about the participants was stored in a cabinet and kept under lock. The file was accessible only to the principal investigator.

Results

Sociodemographic characteristics of respondents

Table 1 shows the Sociodemographic characteristics of the respondents. Most respondents (63.5%) were under 30 years. A similar proportion (n = 226/318, 71.1%) were under 30 years at the time of delivery. Over 60% (n = 203/318) of the respondents had formal education, while 58.2%(n = 185/318) reported that their husbands had formal education. The majority were employed (n = 269/318, 84.6%), whereas most husbands were not civil servants (n = 276/318, 86.8%). Most lived in urban areas (n = 211/318, 67.2%). Household sizes were split, with 57.2% (n = 182/318) having 1–6 members and 42.8% (n = 136/318) having 7 + members. Almost all respondents (n = 303/318, 95.3%) were enrolled in the NHIS. The majority (n = 197/318, 62%) were classified as having a low wealth index.

Table 1.

Sociodemographic characteristics of respondents(n = 318)

Variables	Frequency	Percent
Age At Delivery (unit)
< 30	226	71.1
30 +	92	28.9
Educational level
no formal education	115	36.2
formal education	203	63.8
Husband’s Educational Level
no formal education	133	41.8
formal education	185	58.2
Occupation
no employment	49	15.4
Employed	269	84.6
Husband’s Occupation
none civil servant	276	86.8
civil servant	42	13.2
Ethnicity
Mole Dagbani	275	86.5
Others (akan, ewe, guan)	43	13.5
Marital Status (n = 317)
Single	90	28.4
Married	227	71.6
Religion
Islam	286	90.8
Christian	29	9.2
Residence (n = 314)
Urban	211	67.2
Rural	103	32.8
Type of Family
Nuclear	221	69.5
Extended	97	30.5
Number of Household
1–6	182	57.2
7 +	136	42.8
Maternal Income (GH₵)
None	56	17.6
10 +	262	82.4
Husband Income (GH₵)
100 +	228	71.7
can’t tell’	90	28.3
Monthly Household Expenditure (GH₵)
≤ 1000	145	45.6
1001 +	173	54.4
NHIS status
No	15	4.7
Yes	303	95.3
Wealth index
Low	197	62.0
High	121	38.0

Obstetric characteristics of respondents

Table 2 shows the obstetric characteristics of respondents. The majority (n = 305/318, 95.9%) had singleton births. Most pregnancies (n = 259/318, 81.5%) were term. Vaginal delivery was much more common (n = 290/318, 91.2%). Very few had a previous history of adverse outcomes, such as low birth weight (n = 14/318, 4.40%), abortion (n = 26/318, 8.18%), and pregnancy-related complications (n = 10/318, 3.14%). One-third (n = 116/318, 36.48%) had delayed initiation of antenatal care. Two-thirds (n = 215/318, 67.61%) had fewer than the recommended four antenatal care (ANC) visits.

Table 2.

Obstetric characteristics of respondents (n = 318)

Variables	Frequency	Percent
Type of birth
Singleton	305	95.9
Twin	13	4.1
Gravidity
1–2	202	63.5
3 +	116	36.5
Parity
Nulliparity	105	33.0
Multiparity	213	67.0
Gestational age
pre-term	59	18.5
normal term	259	81.5
Number of pregnancies in the Last 5 years
1	115	36.2
2 +	203	63.8
Plan Pregnancy
No	113	35.5
Yes	205	64.5
Mode of Delivery
Spontaneous vaginal delivery	290	91.2
caesarean section	28	8.8
Previous history of LBW
Absent	304	95.6
Present	14	4.4
Previous history of abortion
Absent	292	91.8
Present	26	8.2
Previous history of stillbirth
Absent	316	99.4
Present	2	0.6
Any obstetric complications
Absent	313	98.4
Present	5	1.6
Family History of HPT
No	301	94.6
Yes	17	5.4
LLINS
No	77	24.2
Yes	241	75.8
Iron supplementation
No	56	17.6
Yes	262	82.4
SP doses
not standard	138	43.4
Standard	180	56.6
Intestinal parasite medicine
Absent	59	18.6
Present	259	81.4
ANC initiation
Delayed	116	36.5
Timely	202	63.5
Number of ANC visits
not recommended	215	67.6
Recommended	103	32.4

Maternal conditions of respondents

Table 3 shows the maternal conditions of respondents. A total of 2.5% (n = 8/318) of the respondents were Hepatitis B positive. Approximately a quarter (n = 76/318, 23.9%) tested positive for H. pylori infection. Very few had preeclampsia (n = 2/318, 0.63%), hypertension at ANC (n = 10/318, 3.14%). Anaemia at the first ANC registration was also high at 38.4% (n = 122/318), and 2.2% (n = 7/318) had sickle cell trait.

Table 3.

Maternal conditions of respondents (n = 318)

Variables	Frequency	Percent
Hepatitis B status
Negative	310	97.5
Positive	8	2.5
Hb delivery
Anaemic	119	37.4
Normal	199	62.6
Helicobater Pylori
Absent	242	76.1
Present	76	23.9
Pre-eclampsia during pregnancy
Absent	316	99.4
Present	2	0.6
Hypertension at ANC
Absent	308	96.9
Present	10	3.1
Hb at registration
Anaemic	122	38.4
Normal	196	61.6
Hb at 36 weeks
Anaemic	132	41.5
Normal	186	58.5
Sickling status
Negative	311	97.8
Positive	7	2.2
HIV status
Absent	308	96.9
Present	10	3.1
Malaria during pregnancy
Absent	295	92.8
Present	23	7.2
Syphilis infection during pregnancy
Absent	316	99.4
Present	2	0.6
HPT before Pregnancy
No	314	98.7
Yes	4	1.3

Prevalence of Caesarean section among respondents

Figure 1 shows the prevalence of caesarean sections among respondents. The prevalence of caesarean sections was 8.8% (n = 28/318) among the respondents.

Fig. 1.

Prevalence of Caesarean section among respondents

Sociodemographic predictors of caesarean section among respondents

Table 4 shows the predictors of the caesarean section among respondents. Of the significantly associated variables, respondents who were above 30 years at the time of delivery were 2.27 times more likely to undergo caesarean section [aOR = 2.27(1.01,5.12)p = 0.048]. In addition, respondents residing in rural areas were 69% less likely to undergo caesarean section [aOR = 0.31(0.10, 0.92) p = 0.036].

Table 4.

Sociodemographic predictors of caesarean section among respondents

Variables	Mode of delivery		cOR (95% CI), p-value	aOR (95% CI), p-value
	SVD (290) n (%)	CS(28) n (%)
Age At Delivery (unit)
< 30	211(93.4)	15(6.6)	Ref	Ref
30 +	79(85.9)	13(14.1)	2.31(1.05–5.08), 0.036	2.27(1.01–5.12), 0.048
Educational level
no formal education	106(92.2)	9(7.8)	Ref
formal education	184(90.6)	19(9.4)	1.22(0.53–2.78), 0.643
Husband’s Educational Level
no formal education	123(92.5)	10(7.5)	Ref
formal education	167(90.3)	18(9.7)	1.33(0.59–2.97), 0.494
Occupation
no employment	44(89.8)	5(10.2)	Ref
employed	246(91.5)	23(8.5)	0.82(0.30–2.28), 0.707
Husband’s Occupation
none civil servant	250(90.6)	26(9.4)	Ref
civil servant	40(95.2)	2(4.8)	0.48(0.11–2.10), 0.331
Ethnicity
Others (akan, ewe, guan)	38(88.4)	5(11.6)	Ref
Mole Dagbani	252(91.6)	23(8.4)	0.69(0.25- 1.93), 0.484
Marital Status
single	83(92.2)	7(7.8)	Ref
married	206(90.8)	21(9.2)	1.21(0.50–2.95), 0.677
Religion
Islam	260(90.9)	26(9.1)	Ref
Christian	27(93.1)	2(6.9)	0.74(0.17–3.29), 0.693
Residence
urban	188(89.1)	23(10.9)	Ref	Ref
rural	99(96.1)	4(3.9)	0.33(0.11–0.98), 0.046	0.31(0.10–0.92), 0.036
Type of Family
Nuclear	198(89.6)	23(10.4)	Ref
Extended	92(94.9)	5(5.1)	0.47(0.17–1.27), 0.136
Number of Household
1–6	165(90.7)	17(9.3)	Ref
7 +	125(91.9)	11(8.1)	0.85(0.39–1.89), 0.697
Maternal Income (GH₵)
none	50(89.3)	6(10.7)	Ref
10 +	240(91.6)	22(8.4)	0.76(0.29–1.98), 0.580
Husband Income (GH₵)
can’t tell	84(93.3)	6(6.7)	Ref
100 +	206(90.4)	22(9.6)	1.50(0.59–3.82), 0.400
Monthly Household Expenditure (GH₵)
≤ 1000	130(89.7)	15(10.3)	Ref
1001 +	160(92.5)	13(7.5)	0.70(0.32–1.53), 0.377
NHIS status
no	14(93.3)	1(6.7)	Ref
yes	276(91.1)	27(8.9)	1.37(0.17–10.82), 0.766
Wealth index
low	178(90.4)	19(9.6)	Ref
high	112(92.6)	9(7.4)	0.75(0.33–1.72), 0.501

Obstetric predictors of caesarean section among respondents

Table 5 shows the obstetric predictors of the caesarean section among respondents. Of the significantly associated variables, respondents who gave birth to twins were 6.88 times more likely to undergo caesarean section than those with singleton births [aOR = 6.88(CI:1.64, 28.95) p = 0.009). Also, respondents who delivered at full term were 79% times less likely to undergo CS [aOR = 0.21(0.08, 0.54) p = 0.002]. Furthermore, respondents with a history of complications were 11 times more likely to undergo CS (aOR = 10.55 (2.42, 46.05) p = 0.002).

Table 5.

Obstetric predictors of caesarean section among respondents

Variables	Mode of delivery		cOR (95% CI), p-value	aOR (95% CI), p-value
	SVD (290) n (%)	CS (28) n (%)
Type of birth
singleton	283(92.8)	22(7.2)	Ref	Ref
twin	7(53.9)	6(46.1)	11.03(3.41–35.65), < 0.001	6.88(1.64–28.95), 0.009
Gravidity
1–2	185(91.6)	17(8.4)	Ref
3 +	105(90.5)	11(9.5)	1.14(0.51–2.53), 0.747
Parity
nulliparity	97(92.4)	8(7.6)	Ref
multiparity	193(90.6)	20(9.4)	1.26(0.53–2.96), 0.601
Gestational age
pre-term	43(72.9)	16(27.1)	Ref	Ref
normal term	247(95.4)	12(4.6)	0.13(0.06–0.30), < 0.001	0.21(0.08–0.54), 0.001
Number of pregnancies in the Last 5 years
1	105(91.3)	10(8.7)	Ref
2 +	185(91.1)	18(8.9)	1.02(0.45–2.29), 0.959
Plan Conception
No	104(92.0)	9(8.0)	Ref
Yes	186(90.7)	19(9.3)	1.18(0.52–2.70), 0.695
Previous history of LBW
Absent	279(91.8)	25(8.2)	Ref
Present	11(78.6)	3(21.40	3.04(0.80–11.63), 0.104
Previous history of abortion
Absent	265(90.8)	27(9.2)	Ref
Present	25(96.2)	1(3.8)	0.39(0.05–3.01), 0.368
Previous history of stillbirth
Absent	289(91.5)	27(8.5)	Ref
Present	1(50.0)	1(50.0)	10.70(0.65–176.0), 0.097
Previous history of complication
Absent	284(92.2)	24(7.8)	Ref	Ref
Present	6(60.0)	4(40.0)	7.89(2.08–29.89), 0.002	10.55(2.42–46.04, 0.002
Family History of HPT
No	277(92.0)	24(8.0)	Ref	Ref
Yes	13(76.5)	4(23.5)	3.55(1.07–11.7), 0.038	3.74(0.95–14.67), 0.058
LLINS
No	74(96.1)	3(3.9)	Ref
Yes	216(89.6)	25(10.4)	2.85(0.84–9.73), 0.092
Iron supplementation
No	49(87.5)	7(12.5)	Ref
Yes	241(92.0)	21(8.0)	0.61(0.25–1.51), 0.286
SP doses
not standard	120(87.0)	18(13.0)	Ref	Ref
standard	170(94.4)	10(5.6)	0.39(0.17–0.88), 0.023	1.04(0.39–2.81), 0.938
Intestinal parasite medicine
absent	49(83.1)	10(16.9)	Ref	Ref
present	241(93.1)	18(6.9)	0.37(0–0.16–0.84), 0.018	0.45(0.17–1.19), 0.107
ANC initiation
delayed	101(87.1)	15(12.9)	Ref
timely	189(93.6)	13(6.4)	0.46(0.21–1.01)
Number of ANC visits
not recommended	192(89.3)	23(10.7)	Ref
recommended	98(95.2)	5(4.8)	0.43(0.16–1.15), 0.093

Maternal predictors of caesarean section among respondents

Table 6 shows the maternal predictors of the caesarean section among respondents. Respondents who had a normal Hb at 36 weeks were 0.18times less likely to undergo CS than their counterparts who were anaemic [aOR = 0.18(CI:0.07, 0.45) p < 0.001].

Table 6.

Maternal predictors of caesarean section among respondents

Variables	Mode of delivery		cOR (95% CI), p-value	aOR (95% CI), p-value
	SVD (290) n (%)	CS (28) n(%)
Hb delivery
anaemic	104(87.4)	15(12.6)	Ref
normal	186(93.5)	13(6.5)	0.48(0.22–1.06), 0.069
Hp
absent	221(91.3)	21(8.7)	Ref
Present	69(90.8)	7(9.2)	1.07(0.44–2.62), 0.886
Hypertension at ANC
Absent	283(91.9)	25(8.1)	Ref	Ref
Present	7(70.0)	3(30.0)	4.85(1.18–19.93), 0.028	3.44(0.79–15.06), 0.101
Hb at registration
anaemic	109(89.3)	13(10.7)	Ref
normal	181(92.4)	15(7.6)	0.69(0.32–1.52), 0.360
Hb at 36 weeks
anaemic	110(83.3)	22(16.7)	Ref	Ref
normal	180(96.8)	6(3.2)	0.17(0.07–0.42), < 0.001	0.18(0.07–0.45), < 0.001
Sickling status
Negative	284(91.3)	27(8.7)	Ref
Positive	6(85.7)	1(14.3)	1.75(0.20–15.10), 0.609
Malaria during pregnancy
Absent	269(91.2)	26(8.8)	Ref
Present	21(91.3)	2(8.7)	0.99(0.22–4.44), 0.985
HPT before Pregnancy
No	287(91.4)	27(8.6)	Ref
yes	3(75.0)	1(25.0)	3.54(0.36–35.25), 0.280

Discussion

Our study in the Tamale Metropolis has provided valuable insights into the prevalence and determinants of caesarean section, shedding light on obstetric and sociodemographic factors influencing CS and its utilisation. Over the last two decades, the choice of delivery for women has become a global subject of interest for both clinicians and researchers due to the gradual increase in the rate of Caesarean Sections [3].

Caesarean section may be seen as a life-saving intervention because of its essence in terms of basic and comprehensive emergency obstetric care, with its impact going beyond saving the mother’s life during an obstetric emergency to preserving the life of the newborn [18]. Because every surgical procedure carries inherent risks, caesarean section (CS) that is not performed under appropriate clinical indications or in adherence to established surgical protocols may increase the risk of maternal and neonatal morbidity and mortality [13]. Caesarean section (CS), though often life-saving, is associated with potential adverse effects such as intraoperative and postoperative hemorrhage, increased risk of infections, delayed recovery, and long-term obstetric complications such as uterine rupture, placenta previa, placenta accreta spectrum, and infertility, all of which may contribute to maternal morbidity and mortality, especially in complicated cases [18]. The WHO has indicated that Caesarean section offers no health benefits for mothers or infants when performed without a medically justified indication [3].

Therefore, it is important to understand the increasing rate of CS and the medical and nonmedical reasons contributing to its performance. These findings have significant implications for maternal health care policy and practice, highlighting the need for targeted interventions to improve maternal and infant outcomes in the Northern region. Specifically, interventions could include strengthening prenatal education to address misconceptions about CS, improving screening and early management of conditions such as anaemia and hypertension during antenatal care, and enhancing access to emergency obstetric services, particularly in rural areas. Additionally, there is a need for capacity building among healthcare providers through regular in-service training, clinical audits, and guideline dissemination to ensure adherence to evidence-based indications for CS and promote shared decision-making. Implementing community outreach programs to increase awareness and trust in vaginal delivery, alongside improving health facility infrastructure and referral systems, could further support the rational use of CS and improve overall maternal and neonatal health outcomes.

Our findings indicate a CS prevalence of 8.8% in the Tamale Metropolis, below the WHO’s recommended rate of 10–15% [8]. It is lower than the average reported in previous studies in different regions in Ghana, indicating potential regional disparities in CS utilization within Ghana. [4, 5, 13]. In contrast, the finding is higher compared to the prevalence of CS in Sub-Saharan Africa [7]. The disparities found in these studies could be driven by medical factors such as obstetric complications, and the influences of non-medical factors such as clinicians’ personal beliefs, knowledge of the woman about CS, finances, and couple’s joint decision. Moreover, maternal requests or demands due to personal reasons other than labour complications can also influence the inequalities in the prevalence of CS in these studies. The belief that CS is less painful, safer, and even healthier than vaginal birth could explain why women may opt for CS. Although caesarean section (CS) is primarily performed to safeguard the lives of the mother and baby when vaginal delivery presents significant risks, some mothers may choose to undergo CS not due to medical or obstetric complications, but based on personal preference or non-medical reasons. This trend is particularly concerning in the field of obstetrics and gynaecology, as the rising CS rates present a growing public health challenge given their implications for maternal and neonatal outcomes [13].

Several key determinants of CS were identified in this study. Maternal age was a significant predictor, with women above 30 years being 2.27 times more likely to undergo CS than younger women. Similar findings were reported by [13, 20, 21]. This finding aligns with the existing literature, which highlights advanced maternal age as a risk factor for CS due to the increased likelihood of maternal complications. The decision to perform a caesarean section (CS) in the context of maternal complications is typically made by healthcare providers, often with the mother’s consent, the increasing frequency of CS has contributed to a growing perception among women that CS is a safe and acceptable mode of childbirth [10, 15]. Older women, particularly those above 35 years, are often not recommended for vaginal delivery by medical professionals due to the increased risk of pregnancy-related complications compared to younger women [11]. Based on medical advice, such women may voluntarily opt for CS compared with younger women.

Residence significantly influenced the likelihood of CS, with rural residents being 69% less likely to undergo CS than their urban counterparts. Alhassan et al. [4] also reported a lower rate of CS among women in rural areas. Similarly, a study in Bangladesh identified a significant urban–rural divide in CS prevalence, with urban areas reporting higher rates [1]. While this difference could reflect broader systemic issues such as access to maternal healthcare, within the context of this study, it may also suggest that women from rural areas either had fewer obstetric complications necessitating CS or were less likely to consent to CS even when medically indicated. Additionally, factors such as perceptions about CS, health-seeking behavior, or cultural preferences may have contributed to the lower uptake among rural dwellers. On the other hand, the convenience associated with CS, interactions with healthcare providers, and the availability of advanced facilities in urban areas may influence higher CS uptake in urban settings, especially within profit-driven private facilities.

The type of birth also played a major role, with women delivering twins having a substantially higher likelihood (6.88 times) of undergoing CS than those with singleton births. Similar findings have been reported by [6] This finding highlights the need for surgical intervention to ensure safe delivery, owing to the increased complexity and possible hazards associated with multiple pregnancies.

Pregnancy duration was found to influence the likelihood of CS, with women who carried their pregnancies to term being 69% less likely to undergo CS than those who had preterm deliveries. This finding may reflect the fact that preterm deliveries are often associated with complications that necessitate surgical intervention. The finding underscores the need for effective antenatal monitoring to detect and manage risk factors for preterm birth, which may in turn help reduce the likelihood of Caesarean delivery.

A history of previous complications was identified as another significant determinant of CS. Women with a previous history of complications such as prior Caesarean delivery, obstructed labor, uterine rupture, placenta previa, or preeclampsia were 11 times more likely to undergo CS than those without such a history. This finding may reflect the cautious approach taken by both obstetricians and patients in cases with prior complications—either due to the fear of recurrence or the actual recurrence of the complication in the current pregnancy. As such, a history of obstetric complications often prompts clinicians to recommend CS to avoid potential risks associated with attempting a vaginal delivery.

Furthermore, maternal haemoglobin levels at 36 weeks of gestation influenced CS likelihood, with women having normal haemoglobin levels 82% less likely to undergo CS than those with abnormal levels. A systematic review and meta-analysis concluded that anaemia during pregnancy is associated with an increased risk of caesarean delivery [2]. This may be because anaemia can contribute to maternal fatigue, reduced oxygen-carrying capacity, and impaired uterine contractions, which increase the likelihood of fetal distress or labor complications necessitating surgical intervention. This finding highlights the importance of maternal health and nutritional status in determining the mode of delivery.

This study suggest that socio-demographic factors (such as age and residence), obstetric history, and maternal health status significantly influence CS rates. Disparities in CS prevalence—especially between rural and urban areas—may be attributed to differences in healthcare access, education, and cultural beliefs about childbirth. There is also a need to explore whether misconceptions about vaginal delivery or perceived advantages of CS contribute to elective CS rates. Educational interventions focusing on the risks and benefits of both delivery modes, coupled with evidence-based counselling during antenatal care, could reduce unnecessary CS procedures and improve maternal and neonatal outcomes.

Conclusion

This study provides valuable insights into the prevalence and determinants of caesarean deliveries in the Tamale Metropolis. While key factors such as maternal age, birth type, haemoglobin levels, and place of residence were identified as significant predictors, the study did not fully explore the underlying reasons for disparities, particularly between rural and urban areas. Additionally, the limited sample size may not fully represent the broader CS prevalence in the region, highlighting a limitation in the generalisability of the findings. Despite these limitations, the results underscore the need for targeted interventions to address inequities in access to maternal healthcare and improve outcomes for mothers and infants.

To address these challenges, health policies should prioritise expanding antenatal care outreach in underserved areas, increasing skilled birth attendance, and improving emergency obstetric care infrastructure. Promoting informed decision-making through community education and personalised counselling could also reduce unnecessary CS procedures. Future research should consider a mixed-methods approach to explore the motivations behind CS decisions from both patient and provider perspectives. This would enhance the development of context-specific, evidence-based strategies to optimise maternal health service delivery and promote safer childbirth experiences in Ghana.

Authors’ contributions

GSA: conceptualisation, statistical analyses, interpreting the data, writing the original draft, final review, and editing. JMW: review and editing. EAA: conceptualisation, review, and editing. UH: review and editing, MAY: review and editing, MK: conceptualisation, review, and editing. The authors read and approved the final manuscript.

Funding

Self-funded.

Data availability

The datasets generated and analyzed during the current study are not publicly available due to limitations of ethical approval involving patient data and anonymity. Still, they are available from the corresponding author at a reasonable request.

Declarations

Ethics approval and consent for participation

Ethical approval for this study was obtained from the Department of Research and Development, Tamale Teaching Hospital. The ethical clearance number for this study was TTH/R&D/SR/152. Written Informed consent to participate in the study was obtained from all the participants before enrolment.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.