Background of the Topic

Caesarean Section (C-section) is a lifesaving surgery required to decrease mortality and morbidity among mothers and neonates in case vaginal delivery is hazardous for either the mother or her baby (Boatin et al., 2018). Yet, in recent decades, there has been a significant epidemiological shift within the global medical practice, and one of its main features is an immense rise in C-section procedures conducted without any medical reasons (Sizear & Rashid, 2024). It is known that historically, the World Health Organization (WHO) established a threshold, stating that 10%-15% of the population C-section rate is the optimal combination for ensuring good health of mothers and babies (Betran et al., 2016; Yaya et al., 2020).

Under 10% of the national rate implies under-utilization or unmet emergency obstetric needs, and above 15% is associated with no more decrease in mortality, which can indicate misuse of this surgery (Boatin et al., 2018). Nevertheless, the statistics around the globe indicate an upward trend in rich and poor countries (Sengupta et al., 2021). Epidemiological evidence suggests that globally the incidence of C-section surgeries increased from around 6% in 1990 to 21.1% in 2018. (Betrán et al., 2021). As estimated through the predictive modeling method, with the current trend continuing, it is expected that by 2030, the global rate of cesarean deliveries will reach 28.5%, which implies that nearly 38 million operations will be performed annually, most of which will be carried out in LMICs (Betrán et al., 2021).

Most importantly, it is worth noting that there exists serious geographical polarization of this trend, as it reaches its peak rate of 42.8% in Latin American region and averages just 5% in regions of Sub-Saharan Africa (Betrán et al., 2021). At the same time, the growth in LMICs is unevenly contributed to by the private healthcare sector, urbanization, greater maternal education, and more affluent socioeconomic strata, making the over-medicalization of deliveries a socioeconomic issue rather than a clinical one.

Public Health Significance

The rising trend of caesarean section is a matter of great concern for public health due to its significant impact on healthcare facilities, resource utilization, health disparities, and national outcomes of maternal and child health. Unnecessary caesarean delivery increases the cost of healthcare due to higher costs of surgical procedure, prolonged hospital stays, increased post-surgical care, and the treatment of surgical complications. The additional cost of unnecessary caesarean deliveries poses a threat to the health-care system of low and middle-income countries such as Pakistan that may have already been overstressed by diverting the resources from other maternal and child health interventions. Moreover, there is significant long-term obstetric morbidity; females having a history of C-section are at higher risk of having abnormal placentation (placenta praevia, placenta accreta), and ectopic pregnancies in subsequent pregnancies (Sandall et al., 2018).

In addition to the risks posed to mothers, there is also an impact on neonates. Babies born by cesarean section without labor are lacking the physiological effects of normal labor, including hormonal spikes that help lung development. Thus, these babies had significantly higher rates of transient neonatal tachypnea and respiratory distress syndrome (Boatin et al., 2018). Longitudinal epidemiological studies have also found that delivery by cesarean section is associated with children's metabolic and immune issues such as asthma, type 1 diabetes, and childhood obesity, possibly due to the different seeding of the microbiome (Sandall et al., 2018). Cesarean sections require substantial input in terms of resources on macroeconomic and healthcare level. In countries with poor healthcare systems, the unnecessary allocation of human resources, operating theater space, surgical equipment, and medications to elective surgical births takes essential resources away from basic preventive measures (Sizear & Rashid, 2024). The misallocation of resources further aggravates healthcare inequality because while commercial private clinics thrive on profit-making, public hospitals struggle with resource scarcity, ultimately leading to poverty stricken people being pushed to incur medical debt (Sizear & Rashid, 2024).

Relevance to Reproductive, Maternal, Newborn, and Child Health (RMNCH)

The increasing trend of C-sections goes against the RMNCH paradigm. Amare (2025) and Kiran et al. (2022) assert that healthcare measures during pregnancy and delivery affect the development of children and the well-being of mothers. The routine practice of unnecessary C-section disrupts many important events along the way. In relation to the health of mothers and babies, C-sections usually delay skin-to-skin contact and breast-feeding. The mother and baby's post-operative pain, mother's sedation from anesthesia, and separation policy in the institutions usually interfere with the initial latch of the baby, leading to the low rates of exclusive breast-feeding, an important RMNCH measure for the reduction of infant mortality rates (Mundra et al., 2024). Additionally, vaginal delivery allows the exposure of the baby to the vaginal microbiome of the mother, an essential process for the primordial colonizing of the child's immune system. By omitting this process, the C-section delivery affects the immune development of the baby, raising long-term public health implications for chronic pediatric diseases (Sandall et al., 2018).

The first C-section carries an effect on the future reproductive path of the individual. It restricts future choices through confining individuals to undergo repeated surgery because of the dangers of vaginal birth after cesarean delivery (VBAC) or the lack of health system infrastructure to facilitate this procedure. For many LMICs, with their relatively high fertility rates, the prevalence of initial C-section results in increasing the risks of severe obstetrical complications during future pregnancies. Lastly, the trend defies the very core mission of the RMNCH to ensure access to quality and humane maternity care. The focus on a high volume of planned surgical interventions driven by the threat of litigation or financial incentives leaves little room for the midwife and low intervention approaches to maternity care (Sizear & Rashid, 2024).

Literature Review:

Global Evidence

Rise in the utilization of caesarean section deliveries during the last three decades worldwide is one of the best documented trends in maternal health care. According to Betrán et al. (2021), based on nationally representative data for 1990-2018, the global CS rate is rising and will amount to 30% by 2030, meaning 38 million operations performed annually. There are also identified two-speed rates of CS increase, as in Eastern Asia, Western Asia and Latin America CS became the main method of delivery. Nevertheless, Sub-Saharan Africa is still under the threshold of 10% needed to guarantee emergency obstetric care. In turn, according to Angolile et al. (2023), the worldwide CS rate increased from around 7% in 1990 to almost 21% during their study period, which is higher than the previous range of 10-15%, which was considered clinically reasonable by the World Health Organization. It is important to note that Angolile et al. (2023) identified that most of the rise could be explained by operations not medically required, such as mother's request for caesarean delivery. According to Sizear & Rashid (2024), there has been an increase in CS deliveries from 16 million in 2000 to 29.7 million in 2020, with a global CS rate of 21.1% using data for 154 countries from 2010-2018. The use of CS varies significantly by region and country. According to a scoping review by Thomaidi et al. (2025), the countries with the highest CS rates nationally were the Dominican Republic, Brazil, Cyprus, Egypt, and Turkey, which have more than 50% CS rate. Other countries in Sub-Saharan Africa, like Chad, Niger, and Ethiopia, have the lowest CS rate, ranging below 3%. This massive disparity is a demonstration of the consistent public health problem in the world literature of the need for CS surgery in poor countries and unnecessary use in rich and now middle-income countries (Thomaidi et al., 2025).

Regional Evidence (South Asia)

South Asia has become one of the regions where CS rates are rising fast on the global scale. Rana et al. (2024) have analyzed the trend in Bangladesh, Nepal, and Pakistan through multiple rounds of DHS data. The authors found that CS became more popular in Bangladesh by rising from 3.5% to 32.8% (2004-2017), in Nepal – from 0.8% to 11.0% (2001-2016), and in Pakistan – from 2.7% to 22.3% (1990-2017) with parallel rise in institutional delivery rate in all these three countries. However, the growth rate has been the fastest in Bangladesh where Sizear and Rashid (2024) found that CS rate rose from 18% in 2011 to 45% in 2022 that is much higher than in neighboring countries. Involvement of the private health care sector and socio-economic status is an often discussed issue in the literature of the region. Neuman et al. (2014) studied almost 46,000 births in underserved areas of Bangladesh, India, and Nepal. It was found that the private and charitable health facilities delivered babies using more frequent cesarean section (73% in Bangladesh compared to 5% in rural India). Moreover, the women with a high education level usually delivered their children in private institutions. According to Verma et al. (2020), who studied the combined data for nine countries in South and South-East Asia, the CS rate is observed predominantly in urban, richer, and more educated women, while institutional births have a higher chance (19%) of having CS compared to the regional rate of 13%(Neuman et al., 2014; Verma et al., 2020).

Evidence from Pakistan

In Pakistan, successive rounds of the Pakistan Demographic and Health Survey (PDHS) reveal an increasing trend of CS utilization. Mumtaz et al. (2017) analyzed PDHS rounds conducted between 1990-91 and 2012-13 and revealed that there was a marked increase in CS use in the country from 2.7% to 15.8%. Notably, there were strong social inequalities: 35.3% of CS utilization was seen among women belonging to the wealthiest quintile while only 5.5% women belonging to the poorest quintile used CS; 40.3% utilization was observed among highly educated women, whereas only 7.5% women with no education used CS. Taking this study further until 2017-18, Amjad et al. (2020) revealed an increase in CS utilization rate up to 19.6%, and age above 24 years, residence in Punjab, wealthiest quintile membership, urban residence, high number of births or first births, higher antenatal care attendance, and private hospital delivery were found to be significant determinants of CS. Using 2012-13 PDHS round data through partial least squares modeling technique, Sadiq et al. (2019) reported that CS utilization was highest among highly educated women (39%) and women belonging to the wealthiest quintile (34%).

Supplemental clinical data can be provided by facility-based studies from multiple provinces. Thus, for instance, in the cross-sectional study conducted in an underdeveloped area of southern Punjab, Rasool et al. (2021) found an unexpectedly high rate of CS of 69.7%, where elective deliveries prevailed over emergency deliveries, and younger maternal age, preterm delivery, and pregnancy complications were regarded as important risk factors. Also, Jadoon et al. (2024) revealed a rate of 44% CS rate in an underdeveloped area, where the majority of surgeries were performed on an emergency basis. Maternal age, education level, and obstetric problems were stated to be important predictors. Applying the framework of the Andersen Health Behavior Model to analyze the situation in Pakistan, Mahfooz et al. (2023) from the Health Services Academy, Islamabad noted that the increase in CS utilization across the country (from 3.1% in 1992 to 22.3% in 2017-18) is associated with the interaction of predisposing (socio-demographic), enabling (economic and facility-related) and need (clinical) determinants, with a special emphasis being placed.

Critical Analysis:

Strengths and Weaknesses of Existing Interventions

Policy Gaps, Programmatic Challenges, and Systemic Barriers

One of the major policy gaps is the absence of any enforceable national policy on C-section that mandates stiff regulatory punishment for conducting non-indicated surgeries. Though some policy guides such as The National Strategic and Accountability Framework on Quality Care for RMNCH do exist, they lack legal weight and enforcement of health policy is fragmented along provincial lines (Hassan et al., 2024). This legal loophole only adds to the leniency of the private healthcare sector because giving birth in private hospitals greatly increases the risk of undergoing a C-section procedure when compared to giving birth in public hospitals (Cready et al., 2025). Private hospitals follow the fee-for-service model and hence have no system of auditing the indications of surgery. Unhealthy healthcare finance policies further worsen the situation; for example, in the national Sehat Sahulat Program, a C-section receives much higher reimbursement from the government than a normal delivery (Cready et al., 2025).

Programmatically, there is a severe limitation in the use of monitoring tools. Robson Ten-Group Classification System recommended by WHO has only been introduced in 57% of public tertiary teaching hospitals from 2020 onwards and not much in private hospitals because there is no legal way of compiling this system (Hassan et al., 2024). Additionally, these pilot programs are extremely donor dependent as there is the use of external funding for workshops for training as well as for the technology needed for data collection and not using budget lines set out by the government, thus making them unsustainable (Hassan et al., 2024). Clinicians are not held responsible for the arbitrary or convenience-based timing of caesarean delivery due to lack of data infrastructure and poor record-keeping in hospitals (CCIT.pk, 2026; Hassan et al., 2024).

As far as the health care system is concerned, chronic shortages of professional maternity staff including well-trained midwives and obstetric nurses result in heavy workload and overcrowded public hospitals. In such circumstances, a physician finds a planned C-section as a faster and more predictable option compared to continuous monitoring of long-lasting natural labor (Veparala et al., 2025). Insufficient referral systems and delays in transferring patients from primary health facilities raise the probability of emergency C-sections in tertiary hospitals (Ali et al., 2025). Lastly, there are many socio-cultural barriers affecting the requirements on the side of demand. The widespread fear of the pain during labor along with the view that the C-section is a safer and less painful way of giving birth or the most modern one leads to the request for an elective operation (Veparala et al., 2025). Family structures patriarchal in nature in South Asian societies diminishes maternal autonomy because the process of birth is controlled by the husband and mother-in-law, not the mother-to-be (Ali et al., 2025; CCIT.pk, 2026; Veparala et al., 2025).

Innovation Component:

The Strategic Governance and Midwifery Integration Framework (SG-MIF)

In response to the growing phenomenon of non-medical C-section deliveries in a highly private-sector-oriented and physician-dominated healthcare system in Pakistan, this project presents a novel structural intervention called Strategic Governance and Midwifery Integration Framework (SG-MIF). By shifting from simple data gathering and fragmented education programs to a more active process of clinical governance and health systems reorganization, the SG-MIF is designed to harmonize the interests of providers with the best evidence and health outcomes. The innovation in the structure is presented in three interconnected pillars:

• Mandatory Dual Authorization and Automated Institutional Audits: For the direct elimination of defensive medicine, convenience of providers, and economic incentives in the private sector, SG-MIF applies a tough digital governance approach. Non-emergent elective C-section delivery procedures need to be managed using a comprehensive digital health register in which clinical clearance is obtained from the attending obstetrician and from a third-party reviewer. This digital health register needs cross-reference of indications for the procedure against defined standards for the booking in the operating room to take place (Metwali et al., 2024). Failure to follow clinical indications leads to a digital peer audit by the hospital, where clinicians must explain their choice of delivery through surgery before the hospital quality assurance committee (Veparala et al., 2025) (Metwali et al., 2024; Sizear & Rashid, 2024).
• Autonomous Midwifery-Led Labor Units (AMLLUs) within Tertiary Care: Since the exclusion of midwives from health institutions in South Asia is a big contributor to overmedicalization in childbirth practices, the SG-MIF develops AMLLUs which are integrated and autonomous units led by midwives. In the strategy, low-risk laboring women (primarily women categorized as Robson Groups 1, 2, 3, and 4) will be managed mainly through the clinical supervision of midwives who have total clinical autonomy. Obstretricians play a secondary role in consulting when some physiologic anomalies and labor arrest arise (Metwali et al., 2024) (Metwali et al., 2024; Sizear & Rashid, 2024).

Financial Re-alignment via Equalized Capitation Bundles: To completely remove the monetary incentives for the performance of high-turnover surgical procedures in the private healthcare industry, the strategy adopts a radical approach to financing of the healthcare sector. Maternity capitation is used under an agreement between the government health insurance scheme (in the case of Pakistan, the Sehat Sahulat program) and private commercial insurers. In such a system, healthcare facilities get paid a set amount of money for providing basic maternity services regardless of how the baby is delivered. If the facility performs an unneeded C-section operation, the higher costs associated with surgery, anesthesia, and medicine will be covered solely by the facility itself rather than being charged to the patient or insurance company (Sizear & Rashid, 2024).

Recommendations:

For Policymakers

1. Regulate private-sector C-section practices through mandatory reporting and licensing requirements.

Private hospitals must be made to submit data on their monthly rates of cesarean section delivery, elective/emergency ratio for cesarean section delivery, and medical indications for cesarean sections. The provincial health commissioners need to tie up the licensing of the hospitals with submission of the above figures as these figures are vital considering the findings of the study.

2. Make the Robson Classification System mandatory across public and private tertiary hospitals.

Robson Classification system needs to be employed across the country for classification of deliveries to identify the categories of women who are responsible for the increased rate of C-section. This could help in identifying the misuse of C-section amongst low risk women. The data should then be integrated into the provincial RMNCH dashboards to monitor and compare the high burden sites.

3. Reform maternity financing to remove incentives for unnecessary surgery.

Insurance schemes in the public and private sector should adopt fixed maternity packages which will reward uncomplicated childbirth in exchange for a certain fee irrespective of whether the childbearing process was natural or by Caesarean section. Any extra fee for Caesarean operations should only be made possible where there is a real need medically.

For Program Managers

1. Establish routine facility-level C-section audit and review mechanisms.

Hospitals need to conduct monthly clinical audits, where a quality assurance committee examines all elective, primary, and repeat c-sections. Hospitals need to review cases using the standard clinical methods, while hospitals having high incidences of low-risk women should be compelled to prepare a corrective plan. This approach is feasible since it can be executed through the existing hospital management and RMNCH monitoring framework.

2. Pilot midwifery-led labour units for low-risk pregnancies.

The program manager needs to initiate birthing units led by midwives in the tertiary and local hospitals whereby the midwives will oversee labor that is normal and low risk whereas the obstetricians come in to help in cases where there are complications. This will ensure that no unnecessary interventions happen, promote normal birth, provide dignified maternity care, and facilitate early breastfeeding and skin-to-skin contact.

3. Strengthen referral systems so that regulation does not delay genuine emergency care.

To reduce unnecessary cesarean deliveries, better referral mechanisms, ambulances, blood transfusion facilities, emergency obstetric preparation, and coordination between the three types of health facilities will be necessary. This is important because Pakistan has a problem of excessive use by city dwellers and private sector users and delayed access to life-saving cesareans by poor and rural women. Reasonable use of cesarean delivery would therefore enhance equality.

For Healthcare Providers

1. Strengthen evidence-based antenatal counselling for women and families.

Health professionals must provide education on the benefits of vaginal births, risks of unnecessary cesarean delivery, alternative pain relief methods, problems with future pregnancies, breastfeeding, and emergency signs. In Pakistan, birth methods are primarily influenced by the spouse and elderly family members. Thus, family-focused therapy should be considered in case of its appropriateness. This will help resolve fears of labor pain, misconceptions about safety of C-section, and poor maternal health knowledge.

2. Require a second clinical review before elective primary C-sections.

Before conducting a planned primary Caesarean delivery for a woman with no emergencies, the responsible doctor must document the rationale behind such a procedure and have it confirmed by another highly skilled colleague. To avoid any unnecessary delays that may prove fatal, emergency Caesareans will have to remain outside of the picture.

3. Improve respectful maternity care to make vaginal birth safer and more acceptable.

There needs to be constant labor support, effective communication, privacy, pain management options, non-violent treatment, and informed consent during childbirth. It is evident that many women will go for a C-section due to issues related to fear of pain, negligence, ineffective communication, and mistreatment during labor. The improvement of the quality of vaginal delivery is thus an important strategy for reducing surgical deliveries.

Table: 1 Descriptive Statistics (N=200)

Descriptive Statistics (N = 200)

Table 1 displays the sociodemographic, obstetric, and perceptual characteristics of the 200 participants involved in the study. In relation to age, most of the respondents belong to the age group of 25 to 29 years (32.5%, n=65), followed by the age group of 20-24 years (29.5%, n=59). Those who belong to the age group of 30-34 years made up 21.0% (n=42), while those above the age of 35 comprised 10.0% (n=20). On the other hand, the youngest age group, below 20 years old, constituted 7.0% of the sample (n=14).

About marital status, most of the respondents (90.0%, n=180) are married, while 8.0% (n=16) were unmarried. Those who are divorced and widowed represented 1.5% (n=3) and 0.5% (n=1), respectively.

The level of education of the participants varied. Most respondents completed secondary education (34.0%, n=68), followed by those who finished upper secondary education (18.5%, n=37). On the other hand, those who completed primary education comprised 17.5% (n=35) of the respondents.

Housewives were the most frequent occupation of respondents (63.0%, n=126). Self-employed women constituted 15.5% (n=31), while employed respondents constituted 11.0% (n=22). Students and responders in other professions accounted for 5.0% (n=10) and 5.5% (n=11) respectively.

The distribution of monthly income was quite even. The biggest part of the respondents (29.5%, n=59) earned more than $100,000 per month, and those who earn between 30,000 and 60,000 comprised 26.5% (n=53). Those who earn less than 30,000 comprised 22.5% (n=45), and those whose income is between $60,000 and $100,000 amounted to 21.5% (n=43).

Almost two-thirds of respondents (64.5%, n=129) lived in rural areas, and 35.5% (n=71) – in cities.

Concerning the number of pregnancies among respondents, 39.5% (n=79) had two or three pregnancies, while 38.0% (n=76) – one pregnancy. Those who had four or more pregnancies accounted for 22.5% (n=45) of the respondents.

With respect to previous delivery location, public hospitals formed the highest percentage (46.5%, n = 93), followed by private hospitals (41.5%, n = 83). Home deliveries formed 10.5% (n = 21), while deliveries at other sites amounted to only 1.5% (n = 3).

Previous method of delivery revealed that normal vaginal delivery was the most common mode of delivery used by the respondents (61.0%, n = 122). Nonetheless, many the respondents had Caesarean sections (39.0%, n = 78).

Previous Awareness about Caesarean Section before conception was equally distributed, with 51.5% (n = 103) of the respondents reporting awareness about caesarean, while 48.5% (n = 97) were not aware of caesarean before. Again, 49.5% (n = 99) of the respondents were informed about their delivery options by health care providers; however, 50.5% (n = 101) of the respondents disagreed with that statement.

The level of satisfaction of the counseling services was equally distributed among the respondents. Majority of the respondents were dissatisfied (21.5%, n = 43), followed by indifferent (21.0%, n = 42) and very satisfied (21.0%, n = 42). 19.5% (n = 39) respondents expressed satisfaction, while very dissatisfied by 17.0% (n = 34).

As far as perceptions of Caesarean Section practices, 34.5% (n = 69) of the respondents were unsure of the fact that a greater number of Caesarean Sections are performed in private hospitals whereas 34.0% (n = 68) of the respondents thought that it is true. Around one-third (31.5%, n = 63) of the respondents rejected this perception.

Likewise, perceptions about financial motivation impacting Caesarean Section practice were also ambiguous. More than one-third (36.0%, n = 72) of the respondents thought that financial motivation plays an important role in this practice whereas 35.5% (n = 71) of them were unsure about it. The remaining 28.5% (n = 57) of the respondents did not think that financial motivation impacts Caesarean Section practice.

The study population mostly comprised of married women, residing in rural areas and reproductive age group with secondary level of education and were housewives. Public hospitals were the most common place for delivery and normal vaginal delivery was the most common mode of delivery practice even though Caesarean Section ratio was high.

Bivariate Analysis: Factors Asso

Table 2 below shows the bivariate analysis conducted to establish whether there exists any relationship between socio-demographic, obstetric and perception variables, and mode of delivery. The Chi-square test was conducted to determine whether the difference between women delivering through caesarean section and those delivering through normal vaginal delivery is statistically significant.

It was found out that age was not significantly related to mode of delivery (χ² = 4.99, p = 0.285). Even though women in the age group of 25-29 years had the highest proportion of Caesarean Section deliveries (47.7%), the differences were not statistically significant. This implies that age did not significantly affect mode of delivery for the women involved in this study.

Similarly, educational attainment was not significantly related to mode of delivery (χ² = 4.46, p = 0.347). Women with no formal education recorded the highest proportion of Caesarean Section deliveries (46.7%) whereas those with graduate or post-graduate education had the lowest proportion (26.7%).

No significant relationship was found between place of residence and mode of delivery (χ² = 0.30, p = 0.583). 42.3% of the urban respondents gave birth through caesarean section delivery whereas 37.2% of rural respondents delivered through caesarean section indicating just a small difference between them.

Monthly income level was not significantly related to mode of delivery (χ² = 6.06, p = 0.108). However, those respondents who earn below 30,000 gave birth to a greater number of children through caesarean section deliveries (51.1%) than those whose monthly income level is within 60,001 to 100,000 (27.9%). Despite these differences, no relationship was statistically significant.

Awareness of caesarean section before the pregnancy was not significantly related to mode of delivery (χ² = 0.00, p = 1.000). Equal percentage of caesarean section deliveries was observed among those respondents who were aware of caesarean section before pregnancy (38.8%) and those who were not (39.2%).

Discussion on delivery options by healthcare providers also showed no significant relationship to mode of delivery (χ² = 1.27, p = 0.259). Slightly higher number of caesarean section deliveries was observed among those respondents who discussed about delivery options with healthcare providers (43.4%) than those who did not discuss (34.7%).

Perceptions on whether private hospitals perform more Caesarean Section were also found to be statistically non-significantly associated with mode of delivery (χ² = 0.82, p = 0.663). The proportion of Caesarean Section deliveries varied between 34.9% for respondents who disagreed and 42.6% for those who agreed with this statement.

Finally, the perception that financial incentives determine decision on performing Caesarean Section had the highest degree of statistical association among all other independent variables, although remaining non-significant statistically (χ² = 4.72, p = 0.094). A larger number of Caesarean Section deliveries (48.6%) was reported by respondents who believed that financial incentives influenced decision to conduct Caesarean Section compared to those who did not believe so (31.6%). Even though this difference was close to the threshold of significance, it could not be considered as such.

In summary, the bivariate analysis revealed that none of the considered variables had any significant association with mode of last delivery statistically at the 5% level of significance. However, the variables like monthly income and perceptions regarding financial incentives had noticeable differences in Caesarean Section rate between categories.

Figure 1 is an illustration of the frequency distribution of the respondents based on their delivery location. It shows that almost half of the respondents (46.5%) gave birth in a public hospital, while the rest of the respondents gave birth in a private hospital (41.5%). Others gave birth at home (10.5%), while a small number gave birth in other places (1.5%). From the results, it can be concluded that institutional deliveries were common amongst the respondents, and public hospitals were mostly used.

The distribution of respondents according to the mode of their last delivery is illustrated in Figure 2 below. It can be seen from the figure that a considerable number of respondents had a normal vaginal delivery (61.0%, n = 122) whereas 39.0% (n = 78) of the respondents had delivery through Caesarean section.