Published in PLOS One on 2026-07-30, this study is presented as an attributed evidence briefing. The excerpts below are the original researchers’ words, reproduced under their Creative Commons Attribution licence. Health Signal has selected the abstract and, where needed, opening background paragraphs; the complete methods, results, limitations and references remain in the linked paper.
Original authors: Kindu Yinges Wondie, Endalk Birrie Wondifraw, Miteku Andualem Limenih, Berihun Agegn Mengistie, Getie Mihret Aragaw, Nuhamin Tesfa Tsega, Zelalem Nigussie Azene, Emma Campbell, Pijush Kanti Khan
Source: PLOS One • DOI 10.1371/journal.pone.0354911
Read the complete primary study ↗ · Creative Commons Attribution licence
From the researchers
Abstract
The overuse of cesarean sections, mainly of primary procedures, is a major contributor to perinatal mortality in Sub-Saharan Africa. The Robson Ten-Group Classification System is the global standard for cesarean section rate. Evidence on the pooled primary cesarean section rate using this system in Sub-Saharan Africa SSA remains limited.
A systematic review and meta-analysis were conducted. PubMed, Scopus, ScienceDirect, Google Scholar, Google, and ResearchGate were searched for studies published between 2001 and February 22, 2025. Data were extracted into Microsoft Excel and analyzed using Stata 17. A random-effects model was applied to calculate the pooled rate. Study quality was assessed using the Joanna Briggs Institute Critical Appraisal Checklist for Studies Reporting Prevalence Data. Publication bias was assessed using a Doi plot and the Luis Furuya-Kanamori index. Heterogeneity was assessed using the I² statistic.
The pooled facility‑based primary cesarean section rate, derived from 25 institution‑based studies (213,117 births; predominantly secondary and tertiary hospitals), in Sub-Saharan Africa was 18.7% (95% CI: 16.2–21.4; 95% prediction interval: 8.4%−36.8%). Robson Groups 1 and 2 were the largest contributors (47.5%), with Group 1 alone accounting for 37.1%. In both nulliparous and multiparous women, primary cesarean section was more common after spontaneous labor than after induction or elective procedures. Significant heterogeneity was observed across studies (I² = 99.64%, p < 0.001). No evidence of publication bias was found (LFK index = −0.27).
The facility‑based primary cesarean section rate in Sub-Saharan Africa exceeded the WHO global reference, with Robson Groups 1 and 2 being the largest contributors. High rates of prelabor cesarean and elevated rates following spontaneous labor raise concern for possible overuse, but unmeasured comorbidities and referral bias cannot be excluded. Stricter adherence to evidence-based protocols, routine use of the Robson classification for clinical audits, and linkage with indication‑level data are essential for improving obstetric care.
Introduction
Cesarean section (CS) is a key indicator of access to safe and timely obstetric care [1]. Globally, CS rates are projected to reach nearly 30% by 2030, with 90% of procedures occurring in resource-limited settings [2]. In Sub-Saharan Africa (SSA), the overall rate remains the lowest worldwide at 7.1% [2]. This paradox, underuse among high-risk women and overuse among low-risk women, drives preventable maternal and neonatal mortality and morbidity [2–6].
Primary CS (PCS), defined as a woman’s first CS, is the main driver of overall CS rates and initiates a cascade of repeat procedures in future pregnancies [7]. PCS is frequently overused in low-risk women for whom vaginal birth is feasible [8], associated with increasing risk of short- and long-term complications [9]. In low-resource, high-fertility settings such as SSA, unnecessary PCS further escalates overall CS rates and associated risks [6]. Reducing unnecessary PCS is therefore a global maternal health priority; monitoring PCS rates is essential to optimize resource allocation, address disparities, and monitor alignment with World Health Organization (WHO) recommendations [10,11].
Reading this evidence
Use the full paper to check the study design, participant selection, comparator and outcome definitions before drawing a practical conclusion. An association does not by itself show cause and effect. A reported performance measure needs its denominator and uncertainty. A finding from a particular facility, sample or time period should retain that scope when it is discussed elsewhere.
This briefing makes the source accessible within the wider hospital systems desk. It does not assess an individual patient or certify a product. When considering relevance to another health system, examine the original authors’ account of context and limitations, then seek local implementation evidence. The related reporting below provides other studies to read alongside this one; it is a topic connection, rather than a claim that their results are directly comparable.
© 2026 Kindu Yinges Wondie, Endalk Birrie Wondifraw, Miteku Andualem Limenih, Berihun Agegn Mengistie, Getie Mihret Aragaw, Nuhamin Tesfa Tsega, Zelalem Nigussie Azene, Emma Campbell, Pijush Kanti Khan. Excerpts reproduced under CC BY. Selection, formatting and contextual notes by Health Signal. The researchers are the authors of the source study, not members of Health Signal’s staff.
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