Cesarean sections are on the rise worldwide — and not always for the right reasons
More cesarean sections are being performed even when the medical need is unclear, a new analysis shows. Researchers warn that the overuse of C-sections in sub-Saharan Africa is putting thousands of women and babies at unnecessary risk.
Globally, the cesarean sections rate has climbed to 21.1% and is projected to hit 28.5% by 2030. While C-sections remain a vital tool in obstetrics — often lifesaving — the dramatic increase has sparked concern. A growing number of these operations are being performed without solid medical justification, raising red flags among maternal health experts.
“This is a cesarean pandemic,” says Sarah Hansen, a medical researcher who has spent years working in Dar es Salaam, Tanzania. “Too many procedures are being done without a clear clinical reason.”
Hansen and a team of researchers studied five of the busiest maternity units in Dar es Salaam. They found that 32% of all births were by cesarean — and 40% of those had no valid medical indication based on pre-defined, localised clinical criteria.
Among the most common questionable reasons for these C-sections were a previous C-section without offering a trial of labor, suspected prolonged labor without actual avidence of slow progress, and fetal distress despite normal fetal heart rate at the time of decision.
“These aren’t just statistics,” Hansen emphasizes. “Unnecessary cesareans put mothers and babies at risk — both immediately and in future pregnancies.”
The findings come from a large-scale, multi-center study conducted by researchers from Aarhus University, the University of Copenhagen, Aga Khan University Tanzania, and five local hospitals — the largest study of its kind in low- and middle-income countries. It examined clinical decision-making in real time to understand how and why cesarean sections were being performed.
Alarmingly, the study also found that most women who needed an urgent, unplanned cesarean did not get it quickly enough. Only 9% had the surgery within one hour of the decision being made, which is the recommended time frame for emergencies. That means 91% experienced delays, likely due to overwhelmed operating rooms, staff shortages, or systemic bottlenecks. These delays can be dangerous, especially when fast action is critical to save the life of the mother or baby.
A city under pressure
“More than half of global births now occur in urban areas, but health systems in many cities simply haven’t kept pace,” says Hansen. “That’s a dangerous mismatch — especially in maternity care.”
The backdrop to this issue is Dar es Salaam — one of the world’s fastest-growing cities. Like many urban centers across sub-Saharan Africa, it is grappling with skyrocketing birth rates, strained healthcare infrastructure, and critical staff shortages.
The study used a retrospective, criterion-based clinical audit, a rigorous method that evaluates whether real-world practices align with established medical standards. The audit criteria were co-developed with local clinicians, using the PartoMa Birth Clinical Practice Guidelines, tailored specifically for the Tanzanian context.
“In overcrowded hospitals with staff shortages, high cesarean rates stretch resources dangerously thin,” Hansen explains. “Unnecessary surgeries mean other women, often those in active labor, are left waiting — increasing their own risk of complications,” explains Hansen.
Considering the staff shortages, high rates of C-sections inevitably divert attention from other labouring women during vaginal birth, increasing their obstetric risks.
The implications go beyond the delivery room. C-sections carry lasting risks, especially in countries with high fertility rates. Scar tissue from one surgery can lead to dangerous complications in later pregnancies, including uterine rupture and abnormal placental attachment.
“Curbing unnecessary cesareans is not just about reducing numbers — it’s about safeguarding women’s health and making sure limited resources are used where they’re needed most,” Hansen highlights.
A pattern of real-world practices across Africa
“This isn’t just about Tanzania,”. With the right systems and support, we can improve care and outcomes for mothers and babies — without defaulting to surgery.”
The drivers identified in Dar es Salaam mirror trends in other urban areas in Kenya, Malawi, and beyond. Rising C-section rates often coincide with a growing urban disadvantage in maternal and perinatal health, where overwhelmed facilities must handle high volumes with limited resources.
“The ultimate goal,” says Hansen, “is to create maternity units that support safe vaginal births while ensuring timely access to cesareans — only when they’re truly needed,” highlights Hansen.
The team’s findings also call for regular clincal audits, context-specific deciison-making tools, and boarder investments in maternity care, especially in cities experiencing rapid population growth.
The results of the study have been discussed with doctors at the included facilities to facilitate a better understanding of the factors that drives unneccesary cesarean sections.
“We need bold action to make sure urban healthcare systems work for everyone,” says Hansen. “This means shifting towards a collective, evidence-based decision-making and away from resource-consuming ‘defensive decision-making’ for cesarean sections. The demand for facility births is growing faster than health systems can keep up, and we can’t afford to let clinical care fall behind.”
Contact:
Sarah Hansen
(affiliation and email address)