Why do cesarean delivery rates persistently rise despite evidence-based efforts to reduce them?

Document Type

Article

Department

Obstetrics and Gynaecology (East Africa); Centre of Excellence in Women and Child Health

Abstract

Background Globally, cesarean delivery rates have increased steadily over the past 3 decades, beyond medically indicated limits. Research in the area tends to analyze clinical indications, with little attention to the nonclinical factors that are drivers of these increasing rates. This integrative review systematically synthesizes evidence on the structural, systemic, and sociocultural contributors to the global increase in cesarean delivery rates.

Objective Critically identify the nonclinical determinants of global cesarean section overuse.

Study Design A comprehensive integrative review of 144 article studies published between January 1990 and May 2025 that employed a hybrid deductive-inductive thematic synthesis approach was conducted. Articles were sourced from 6 databases and evaluated using the Critical Appraisal Skills Programme, the Mixed Methods Appraisal Tool, and a combined Authority, Accuracy, Coverage, Objectivity, Date, and Significance checklist with a policy relevance lens. Retained studies were categorized according to region, methodological design, and thematic focus. Deductive coding was used to develop a priori frameworks on legal, economic, health system, and rights-based drivers, whereas inductive coding was used to reveal emergent themes not explicitly theorized in previous literature.

Results Of note, 5 core nonclinical drivers were identified: (1) medicolegal anxieties and defensive medicine; (2) financial and insurance-based incentives; (3) sociocultural preferences and aesthetic motivations; (4) health system weaknesses, including staffing and service delivery inefficiencies; and (5) reproductive rights and informed consent violations. These drivers intersected with 3 emergent themes: (1) media influence and digital normalization; (2) provider convenience and scheduling practices; and (3) patient mistrust, particularly among marginalized women. Studies revealed stark regional asymmetries: Latin America displayed the highest cesarean delivery rates, linked to private sector incentives and cultural constructs, and Africa and South Asia highlighted underuse or coerced use in public systems. Methodologically, most studies lacked intersectional or longitudinal designs, limiting insights into disparities and policy evolution.

Conclusion Increasing cesarean delivery rates are the cumulative result of multiple drivers, such as structural imbalances, commodification of care, and institutional accountability gaps, and not just due to clinical processes. The interplay of profit, litigation fears, and social narratives drives unnecessary cesarean deliveries, whereas rights violations and systemic mistrust disproportionately affect vulnerable women and girls. Addressing these drivers will require multisectoral reforms, such as bundled payment models, consent safeguards, legal frameworks protecting both patients and providers, and regulation of digital health content. Future research should integrate intersectional and implementation science frameworks to generate actionable, equity-sensitive solutions for the sustainable reduction of cesarean delivery rates.

AKU Student

no

Publication (Name of Journal)

American Journal of Obstetrics and Gynecology

DOI

https://doi.org/10.1016/j.ajog.2025.08.014

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