Geospatial inequalities and determinants of caesarean section delivery in sub-Saharan Africa: a multi-country analysis

Abstract

Background Cesarean section is a lifesaving obstetric intervention when medically indicated; however, its utilization remains unequal across sub-Saharan Africa (SSA). Although the World Health Organization recommends cesarean section rates of 10–15%, access remains insufficient in many low-resource settings and excessive in others. Understanding geographic patterns and drivers is essential for maternal health planning.Objective(s) To examine the spatial variation and determinants of cesarean section delivery across SSA.Methods We conducted a cross-sectional analysis using Demographic and Health Survey data (2015–2024) from 201,481 weighted samples across 28 SSA countries. Spatial autocorrelation and hotspot patterns were assessed using Global Moran’s I and Getis-Ord Gi* statistics. Spatial regression models, including ordinary least squares, spatial lag, spatial error, geographically weighted regression, and multiscale geographically weighted regression, were fitted. Model performance was compared using corrected Akaike Information Criterion and adjusted R2.Results Cesarean section delivery showed significant spatial clustering (Moran’s I = 0.18, z = 43.3, p < 0.01). Hotspot areas were identified in Uganda, Rwanda, Burundi, Kenya, Tanzania, Malawi, South Africa, Lesotho, Gabon, Ghana, and Senegal, while cold spots were observed in Ethiopia, Madagascar, Angola, Nigeria, Guinea, Cote d’Ivoire, Sierra Leone, Liberia, and Mauritania. Previous cesarean delivery, maternal age ≥35 years, pregnancy spacing behavior, and health insurance coverage were significant spatial predictors.Conclusion Cesarean section utilization in SSA exhibits substantial geographic inequality driven by context-specific determinants. Spatially targeted maternal health policies, improved referral systems, and equitable financing mechanisms are needed to optimize access to medically indicated cesarean delivery while minimizing unnecessary procedures.