Global Preferences and Determinant Variables of Caesarean Delivery Among Pregnant Women: A systematic review and meta-analysis

Summary

A caesarean section (CS) is a lifesaving procedure. With rising rates, women's delivery choices have become a global concern. This review assesses global CS preference and determinants. A search of 6 databases was conducted (PubMed, Medline, EMBASE, CINAHL, Google Scholar and Maternity and Infant Care) in accordance with PRISMA guidelines, including papers published between 2013 and 2024. Egger's test and funnel plot assessed publication bias, while the I² statistic and Cochrane Q-test evaluated heterogeneity. Subgroup analysis considered sample size, publication year and economic condition. Initially, 73 articles were identified, of which 13 were deemed suitable, with a total sample size of 22,238. The pooled global CS preference was 26%. Subgroup analysis considered economic status, publication year and sample size. Variables associated with CS preference included age >25 years (adjusted odds ratio [AOR] = 4.9, 95% confidence interval [CI]: 1.4–8.4), higher education (AOR = 1.7, 95% CI: 1.05–2.3), urban residency (AOR = 1.9, 95% CI: 1.4–2.4), lack of knowledge of CS (AOR = 2.1, 95% CI: 1.5–3.6) and prior pregnancy complications (AOR = 4.8, 95% CI: 1.4–10). The pooled global CS preference was nearly one-fourth. This review found that an age greater than 25 years, higher education, urban residency, lack of knowledge about CSs and history of previous pregnancy complications were determinant factors for preference for caesarean delivery. As a result, strengthening healthcare systems is essential to improve women's decision-making regarding mode of delivery.

1. Introduction

A caesarean section (CS) is a surgical treatment intended to treat or prevent serious complications that could endanger the lives of the mother or fetus. Many factors influence the delivery method decisions made by pregnant women, who typically participate in this process.1 A person's environment, values, personality, knowledge and insight all have an interactive impact on these processes.2 In situations where a vaginal delivery would endanger the mother's or baby's life, a CS is frequently performed. Certain procedures are also carried out on demand, without medical justification.3 In spite of the World Health Organization's 4 recommendations, the use of CS as a common method of delivery, along with technological advancements in childbirth care, has become widespread.4,5 The WHO recommends an acceptable rate of CS to be between 10% to 15%, but the steady rise in the number of CSs has made women's preferences for delivery mode an international topic of interest for many researchers and clinicians.6 In contemporary obstetric practice, the right to choose one's preferred delivery method is essential for providing compassionate and respectful care as it promotes the well-being of both the mother and the newborn.7 Primary CS rates have increased globally in modern obstetric practice for legal, social, medical and economic reasons; exemplary research indicates that Port Elizabeth, South Africa, has the highest percentage of CSs (55.6%).8,9 The rate of CS is 40.5–42% in Latin America, 32% in southern India, 42.4% in South Africa and 20.2–38.3% in Ethiopia.10,11,12 Positive remarks on vaginal birth were given by the majority of women (68.7%), who thought it involved less pain, better recovery, lower risk, quicker recovery, earlier hospital discharge and was better for both mothers and their newborns.13 Numerous pieces of data demonstrate that pregnant women typically participate in the process of choosing the method of delivery and that a variety of circumstances influence their choice. A person's environment, values, personality, knowledge, and insight all have an interactive impact on these processes. 2 In high-income countries, 5–20% of women prefer CS; in low-income countries, 1–4% prefer them.14 Most women give birth vaginally.15 Evidence shows that perceptions of safety, fear of pain, prior birth experience, discussion and encouragement from healthcare professionals, social and cultural influences, information availability and educational attainment are some of the factors linked to preferred delivery methods.16 Fear of episiotomies, protracted and painful labour, pelvic floor injuries and the incontinence associated with vaginal birth have all contributed to a rise in mothers requesting CSs.17 Therefore, this systematic review and meta-analysis aimed to assess global CS preferences and their determinant factors among pregnant and labouring women.

2. Methods

2.1. Study selection

The systematic review was developed using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses checklist.18 The protocol for this review was registered in the PROSPERO database (CRD42024533707). Articles were identified through a comprehensive search of electronic databases. Initially, titles and abstracts were screened for relevance; two reviewers independently screened all titles and abstracts, and discrepancies were resolved through discussion or consultation with a third reviewer. Full texts of potentially relevant studies were then retrieved and assessed for eligibility using predefined inclusion and exclusion criteria. Full-text screening was again conducted independently by the two reviewers. To ensure completeness, the reference lists of included articles were manually reviewed to identify additional relevant studies.

2.2. Criteria for inclusion of studies

Cross-sectional English-language full-text studies reporting prevalence of CS preference and its associated factors among pregnant and labouring women between 2013 and 2024 (up until 25/04/2025) that were either hospital- or community-based were considered. The participants included pregnant and labouring women from any country who expressed their preference for mode of delivery. The denominator was defined as women surveyed regarding their mode of delivery preference, and the numerator included only those who expressed a preference for CS. Women who underwent caesarean delivery for medical indications were not counted in the numerator. Studies that primarily focused on CSs performed for clinical/medical reasons or that reported unrelated outcomes were excluded [Supplementary Table 1]. Articles reporting outcomes outside of the scope of interest, as well as those without complete abstracts or full texts, were excluded. Following an examination of the full texts, citations without abstracts and/or full texts, commentaries, anonymous reports, letters, editorials, and reviews were also excluded.

2.3. Search strategy

A comprehensive search was conducted using electronic resources PubMed, Medline, EMBASE, CINAHL, Google Scholar and the Maternity and Infant Care databases on all papers published between 2013 and 2024. Searches were conducted in PubMed and Medline using terms such as ‘(((C-section preference [MeSH Terms] AND associated factors AND determinants) OR factors) AND cross-sectional)’. For CINAHL and EMBASE: ‘caesarean section preference AND associated factors AND determinants OR factors AND cross-sectional’. For Google Scholar: ‘women OR mothers AND caesarean section preference AND associated factors AND determinants OR factors AND cross-sectional’. For the Maternity and Infant Care database: ‘caesarean section delivery preference AND associated factors’.

2.4. Data extraction

Using a data extraction tool that our team developed with specified inclusion and exclusion criteria, data were extracted from the papers included in the review. This data extraction sheet was created by all authors, who verified that it would adequately collect the information needed to address the review questions. Data were retrieved from the included studies by two authors. The following information was recorded: exposure measurement, the last name of the author(s) for each included study, participants' age, previous pregnancy complications, women's residence (urban), higher education and lack of knowledge regarding CS. The extracted data included the study's methodology (setting, study design, year of data collection, sample size and data analysis), the odds ratios of associated variables with 95% confidence intervals and the percentage of CS preference. The principal authors of the articles were contacted when additional information was needed to clarify any ambiguities.

2.5. Risk of bias (quality) assessment

The methodological quality of the cross-sectional studies was assessed using the Newcastle-Ottawa Scale, which is used to evaluate the quality of cross-sectional studies in systematic reviews and meta-analyses, in order to gauge the risk of bias within the included research.19 Three authors evaluated the methodological quality, sample selection, sample size, result comparability and statistical analysis of each study. When the three authors could not agree, another two authors intervened and worked out a solution. This systematic review and meta-analysis comprised only cross-sectional studies [Table 1].

Table 1.

Quality assessment of included studies of global preference and determinant variables of caesarean section among pregnant women using Newcastle-Ottawa Scale assessment tool.^{2,26,27,28,29,30,31,32,33,34,35,36,37}

	Selection				Comparability outcome	Outcome		Total
Author and year of publication	Representati- veness of sample size	Sample size justified	Non- response rate	Ascertainment of the-exposure (max ++)	Cofounding controlled max (max ++)	Outcome assessment (max ++)	Statistic caesarean section	Total score (max 10)	Over all quality
Parvej et al.37 (2021)	+	+	−	+	++	++	+	8	Good
Rossetto et al.35 (2020)	+	+	−	+	++	++	+	8	Good
Liang et al.33 (2018)	+	+	−	+	++	++	+	8	Good
Sun et al.32 (2020)	+	+	−	+	++	++	+	8	Good
Welay et al.36 (2021)	+	+	−	+	++	++	+	8	Good
Zewudu et al.27 (2024)	+	+	+	+	++	++	+	9	Very good
Tenaw et al.26 (2019)	+	+	+	+	++	++	+	9	Very good
Adu-Bonsaffoh et al.31 (2022)	+	+	−	+	++	++	+	8	Good
Maharlouei et al.30 (2013)	+	+	−	+	++	++	+	8	Good
Chelangat et al.2 (2021)	+	+	−	+	+	++	+	7	Good
Amjad et al.29 (2018)	+	+	−	+	++	++	+	8	Good
Akkus et al.28 (2017)	+	+	+	+	++	++	+	9	Very good
Silva et al.34 (2020)	+	+	−	+	+	++	+	7	Good

+ = 1 point; ++ = 2 points; = criterion not adequately reported.

2.6. Data processing and analysis

First, a few selected articles were entered into a Microsoft Excel spreadsheet and exported to STATA, (STATA Corporation, College Station, Texas, USA), Version 17 for statistical analysis. The weighted prevalence of CS preference in different countries was estimated using a weighted inverse-variance random-effects model. A random-effects model in the case of heterogeneous studies was used, whereas the fixed-effects model was applied when studies had an I² ≤ 50%. To evaluate heterogeneity across all studies, the Cochrane Q-test and I² statistic were calculated. The funnel plot was generated based on transformed values using the Freeman–Tukey double arcsine transformation to stabilise the variance. In accordance with the I² results, there are four levels of heterogeneity: mild, moderate, substantial and considerable. Mild heterogeneity is characterised as occurring between 0% and 40%, moderate heterogeneity between 30% and 60%, substantial heterogeneity between 50% and 100% and considerable heterogeneity above 75%. To evaluate publication bias, the Egger's test and funnel plot were utilized.20,21 A P >0.05 indicated that there was no publication bias. Based on the sample size, a subgroup analysis was conducted. The pooled prevalence of CS preference and its associated factors, with 95% confidence intervals, was displayed using a forest plot. Mendeley Reference Manager was used to manage references

3. Results

Initially, 73 articles were identified, of which 13 were deemed suitable and included a total sample size of 22,238.2,26,27,28,29,30,31,32,33,34,35,36,37 Using a comprehensive search strategy, 73 articles related to CS preference and associated factors were retrieved. After removing duplicates and articles in other languages, 35 unique articles remained. Screening based on titles excluded 14 articles due to lack of reported prevalence or irrelevant content, and an additional 8 were excluded based on their outcome variables. Consequently, 13 articles met the inclusion criteria for the final systematic review and meta-analysis [Fig. 1].

Fig. 1.

Flowchart showing the selection process of studies included in the systematic review and meta-analysis on global Caesarean section preference and associated factors.

3.1. Global prevalence of caesarean section preference

The combined magnitude of caesarean section preference, as determined by pooled data from 13 studies, was 26% with a 95% confidence interval of 19–32% (I² = 99.2%; P <0.001), using the random-effects model [Fig. 2].

Fig. 2.

Forest plot of the prevalence estimates from 13 included studies.

Each horizontal line represents an individual study with its effect size and 95% confidence interval (CI). The square markers indicate the point estimates, with larger squares representing studies with higher weights in the meta-analysis. The diamond in the Overall row shows the pooled prevalence estimate with its 95% CI, calculated using a random-effects model.

CI = confidence interval.

3.2. Publication bias

Both Begg's and Egger's tests showed non-significant P values and the funnel plot did not display any strong visual asymmetry. Together, these results suggest that there is no substantial publication bias in our meta-analysis [Fig. 3]. No small-study effect was observed in the results of Begg's test (P = 0.8922) and Egger's test (P = 0.8828). Furthermore, a non-parametric trim-and-fill analysis was performed to address publication bias; however, no imputed studies were identified.

Fig. 3.

Funnel plot of studies on caesarean section preference.

Each point represents a study, plotted by standard error and effect size to assess publication bias. The plot was generated using the Freeman–Tukey double arcsine transformation to stabilise variance. All 13 studies from the forest plot [Fig. 2] are included.

CI = confidence interval.

3.3. Subgroup analysis of global prevalence of caesarean section preference

High heterogeneity was observed among studies (I² = 92.22%). Subgroup analyses were performed based on publication year, sample size and country economic status. However, the limited number of studies in each subgroup, combined with the high heterogeneity, may have introduced overestimation or bias in the pooled estimates. In studies with sample sizes <799, the pooled prevalence of CS preference was 30% (95% CI: 0.19–0.41, I² = 98.1%; P <0.001).22,23,24,25,26 Likewise, studies conducted before 2020 reported a prevalence of 31% (95% CI: 0.22–0.39, I² = 99.4%; P <0.001).22,23,24,25,26,27,28,29 Subgroup analysis by economic status showed that, for low-income countries, the prevalence was 33.7% (95% CI: 21.6–48.3, I² = 95.9); for lower-middle-income countries it was 13.1% (95% CI: 10.2–16.7, I² = 82.6); and for upper-middle-income countries it was 29.4% (95% CI: 20.2–40.6, I² = 99.1) [Table 2]. These estimates should be interpreted in light of the small number of studies per subgroup and the high between-study heterogeneity.

Table 2.

Characteristics of included studies on global caesarean section preference among pregnant women.

Author and year of publication	Country/setting	Income status*	Study design	Inclusion criteria	Sample size	Assessment method	Outcomes assessed
Parvej et al.37 (2021)	Bangladesh	2	Cross-sectional	Pregnant women attending ANC	340	Structured questionnaire	Caesarean section preference and factors
Rossetto et al.35 (2020)	Brazil	3	Cross-sectional	Women in 3rd trimester	343	Interview-based questionnaire	Caesarean section preference and factors
Liang et al.33 (2018)	China	3	Cross-sectional	Expectant mothers (≥28 weeks)	1,669	Self-administered survey	Caesarean section preference and factors
Sun et al.32 (2020)	China	3	Cross-sectional	Pregnant women	1,853	Validated questionnaire	Caesarean section preference and factors
Welay et al.36 (2021)	Ethiopia	1	Cross-sectional	Low-risk pregnant women	398	Interview method	Caesarean section preference and factors
Zewudu et al.27 (2024)	Ethiopia	1	Cross-sectional	Women attending antenatal care	512	Interview-based survey	Caesarean section preference and factors
Tenaw et al.26 (2019)	Ethiopia	1	Cross-sectional	Pregnant women at health centres	300	Structured interview	Caesarean section preference and factors
Adu-Bonsaffoh et al.31 (2022)	Ghana	2	Cross-sectional	Pregnant women at health centres	415	Structured interview	Caesarean section preference and factors
Maharlouei et al.30 (2013)	Iran	2	Cross-sectional	Pregnant women at ANC	6,921	Self-administered questionnaire	Caesarean section preference and factors
Chelangat et al.2 (2021)	Kenya	2	Cross-sectional	Pregnant women attending ANC	310	Structured survey	Caesarean section preference and factors
Amjad et al.29 (2018)	Pakistan	2	Cross-sectional	Pregnant women	7,461	Face-to-face interviews	Caesarean section preference and factors
Akkus et al.28 (2017)	Turkey	3	Cross-sectional	Low-risk pregnancies	628	Questionnaire	Caesarean section preference and factors
Silva et al.34 (2020)	Brazil	3	Cross-sectional	Pregnant women in late trimester	1,088	Structured interview	Caesarean section preference and factors

ANC = Antenatal care.

^*Lower income = 1; Middle income = 2; Upper-middle income = 3.

3.4. Sensitivity analysis

A leave-one-out sensitivity analysis was conducted to assess the robustness of the pooled prevalence estimate. In this approach, each study was excluded one at a time and the pooled prevalence was recalculated. The estimates ranged from 7–60%, all within the overall confidence interval, indicating that no single study substantially influenced the overall results. Year and country were not included in this sensitivity analysis because this method specifically examines the effect of removing individual studies rather than study-level characteristics.

3.5. Factors associated with global caesarean section preference

In this systematic review and meta-analysis, 5 factors were identified as positively affecting women's preference for CS among all the retrieved articles. The aggregate effect of 4 studies revealed that women older than 25 years had 4.9 times higher odds (adjusted odds ratio [AOR] = 4.9, 95% CI: 1.4–8.4) of preferring CS than women younger than 25 years.29,23,25,30,31 Likewise, the combined results from 2 studies indicated that women with an educational status of high school or above had 1.7 times higher odds (AOR = 1.7, 95% CI: 1.05–2.3) of preferring caesarean delivery compared to women with an educational status below high school.2,29 Furthermore, combining the findings of 4 studies revealed that women living in urban areas had 1.9 times higher odds (AOR = 1.9, 95% CI: 1.4–2.4) of preferring CS compared to women not living in urban areas.30,31,32,33 The combined effect of 2 studies showed that women who lacked knowledge about CS had 2.1 times higher odds of preferring CS (AOR = 2.1, 95% CI: 1.5–3.6) compared to women who were knowledgeable about CS.2,29 The pooled effect of 3 studies showed that women who had experienced a previous pregnancy complication had 4.8 times higher odds of preferring CS (AOR = 4.8, 95% CI: 1.4–10) compared to women who had not experienced a previous pregnancy complication.27,29,32

4. Discussion

This review aimed to assess the global preference for CS and its determinant factors among pregnant and labouring women. After reviewing and analysing the data, all associated variables were discussed in the context of different systematic reviews and meta-analyses, from local to global, that examined preferences for CSs. The preference of women regarding their mode of delivery is a topic that has generated considerable discussion and research worldwide. Women's autonomy, satisfaction during childbirth and active involvement in choosing how they wish to give birth are becoming increasingly significant. This global review identified an overall prevalence of preference for CSs of 26%, with a 95% confidence interval of 19–32%. This result is consistent with findings from other studies in Africa, although the current review reports a higher prevalence compared to some African studies.38 The estimated prevalence of CS preference appears to be influenced by the characteristics of the included studies, particularly their setting (e.g., hospital-based versus community-based populations, antenatal versus intrapartum women). The possible explanation for this difference may be related to the study area, sample size and study period. Studies conducted in Africa did not include countries outside the continent, often had smaller sample sizes and some articles were outdated. The prevalence of CS may have increased over the past 10 years. Similarly, evidence shows that the pooled prevalence of CS from studies conducted over 10 years ago was lower than the current findings.39 In addition, a mixed-methods systematic review conducted in Iran reported a prevalence lower than the current findings.34 The differences may be partly explained by the impact of globalisation on women's decisions regarding their preference for caesarean delivery. Other variations, such as national obstetric guidelines, may also contribute to differences in CS rates and maternal preferences across countries. For example, the WHO recommends that CSs should only be performed when medically necessary, while some high-income countries have more flexible policies allowing caesarean delivery upon maternal request. In contrast, low-resource settings may follow stricter criteria due to limited surgical capacity or different health policy priorities.4 This finding indicates that the pooled prevalence of CS preference is higher than that reported in previous studies and by the WHO.

In the current review, it was observed that pregnant women older than 25 years had 4.9 times higher odds of preferring CS compared to women younger than 25 years. A possible reason may be a fear of labour or delivery complications associated with their age. Although the exact causes of the increase in CS preference among older women are unknown, it is thought that older mothers are more likely to experience pregnancy complications that could result in caesarean deliveries.35

Likewise, the combined results from 2 studies indicated that women with an educational status of high school or above had 1.7 times higher odds of preferring CS compared to women with an educational status below high school. According to a prior single study from Iran, higher education of men is associated with a preference for CSs.36 The possible reason is still unclear, but it may be related to women who have misconceptions about the outcomes of CS and/or women with higher education who believe a CS is more suitable and safer than spontaneous vaginal delivery. This is supported by other systematic reviews in Africa and is linked to women of high socio-economic status.

In this study, women living in urban areas had 1.9 times higher odds of preferring caesarean delivery compared to women living in rural areas. This finding is consistent with systematic review and meta-analysis studies conducted in Africa. The possible explanation is that women living in urban areas are more willing to pay the higher costs of caesarean deliveries and are more likely to be well-educated, informed and aware of the procedure. Living in an urban area also facilitates access to high-quality hospitals with CS capabilities.

In this review, the combined effect of 2 studies showed that women lacking knowledge about CSs had 2.1 times higher odds of preferring CS compared to women who were knowledgeable about CSs. A plausible explanation is that misinformed pregnant women, or those without adequate knowledge about CSs, may not fully understand the health risks associated with caesarean delivery for both the mother and the fetus.37 An additional reason may be related to women who have had previous CS experiences and have become familiar with the procedure.39

The pooled effect of 3 studies showed that women who had previous pregnancy complications had a 4.8 times higher preference for CS compared to women who had not had previous pregnancy complications. This finding is consistent with a systematic review and meta-analysis conducted in Africa and with Williams's Obstetrics textbook.38,39 A possible explanation may be a fear of pregnancy, intrapartum and postpartum complications for both the mother and the newborn.

In general, given the high rates of CS identified in this review, this study supports the global recommendation to reduce unnecessary procedures to 10–15% without compromising maternal or fetal health. Effective strategies include antenatal education about delivery options, shared decision-making with healthcare providers, continuous midwifery support and appropriate labour monitoring tools such as the partograph. Policy-level changes, including reviewing hospital incentives and auditing CS indications, may also help reduce unnecessary use while maintaining safety.4,40 Therefore, this systematic review and meta-analysis provides the pooled prevalence and determinant factors of global CS preference.

4.1. Strength and limitations

The primary strength of this study is that PRISMA was strictly followed and six databases were searched for relevant papers. However, there is a high degree of heterogeneity among the included studies and settings which may have influenced the pooled prevalence estimates and subgroup analyses, potentially leading to overestimation or bias. Studies reporting different outcome variables could not be reported. Additionally, the included studies are geographically limited, which reduces the generalisability of the findings; therefore, the term ‘global’ in the title should be interpreted with caution. This review was unable to perform pooled evaluations of associated variables at the continental level due to a lack of comparable outcomes across studies. Nevertheless, because there are many single cross-sectional studies in individual countries, this review provides scientific justification for the findings even in the absence of equivalent systematic reviews or meta-analyses for direct comparison.

5. Conclusion

The analysis of the 13 included studies estimated the global prevalence of CSs to be approximately one-fourth. This review identified several significant factors influencing women's choice of caesarean delivery, including age above 25 years, higher educational attainment, urban residency, lack of understanding regarding CSs and a history of pregnancy complications. To address these determinants, healthcare systems should be strengthened to support informed decision-making regarding the mode of delivery. Furthermore, longitudinal studies are needed to gain a better understanding of the factors that influence women's delivery choices over time. This review highlights strategies for building effective healthcare systems and is critical for improving maternal decision-making regarding the preferred mode of delivery. Policymakers and healthcare professionals can use these findings to enhance initiatives aimed at reducing inequities and promoting adherence to essential maternity care, regardless of the mode of delivery. Furthermore, this review emphasises the importance of educational interventions to help mothers make informed choices about delivery options. Additionally, healthcare practitioners should prioritise providing accurate information, education, clinical care and initiatives that improve maternal and newborn outcomes in alignment with the mother's chosen mode of delivery.

Authors' Contribution

Mitiku Tefera: Conceptualization, Methodology, Software, Data curation, Validation, Visualization, Writing – original draft, and Writing – review & editing; Lijalem Jemberu: Conceptualization, Methodology, Software, Data curation and Validation: Eyob Getachew: Conceptualization, Methodology, Software, Data curation and Validation: Getnet Alemu Andarge: Methodology, Software, Data curation, Validation and Visualization: Kedir Seid: Methodology, Software, Data curation, Validation and Visualization: Gebeyehu Lakew: Methodology, Software, Data curation, Validation and Visualization: Amlaku Nigusie Yirsaw: Conceptualization, Methodology, Software, Data curation and Validation: Eyob Ketema Bogale: Conceptualization, Methodology, Software, Data curation and Supervision.

Acknowledgement

The authors would like to especially acknowledge all the authors of the included primary studies.

Conflict of Interest

The authors declare no conflicts of interest.

Funding

No funding was received for this study.

Data Availability

Data is available upon reasonable request from the corresponding author.