R E S E A R C H Open Access © The Author(s) 2025. Open Access This article is licensed under a Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International License, which permits any non-commercial use, sharing, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if you modified the licensed material. You do not have permission under this licence to share adapted material derived from this article or parts of it. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit h t t p : / / c r e a t i v e c o m m o n s . o r g / l i c e n s e s / b y - n c - n d / 4 . 0 /. Nahayo et al. BMC Public Health (2025) 25:794 https://doi.org/10.1186/s12889-025-21967-2 BMC Public Health *Correspondence: Bonfils Nahayo bonfils.nahayo2@gmail.com Full list of author information is available at the end of the article Abstract Background Caesarean Section (CS) is one of the commonest surgical procedures worldwide. It is an important medical intervention for reducing the risk of poor perinatal outcomes. However, there was increased trends in CS in sub-Saharan Africa as maternal and neonatal mortality and morbidity remains high. This study aims to determine the prevalence and factors associated with CS rates in Tanzania. Methodology This was a secondary data analysis of 4,768 women of reproductive age (15–49) in Tanzania. The data utilized was from the Tanzania Demographic Health and Survey (TDHS) 2022. The factors associated with CS were identified using multivariable binary logistic regression. Results Out of 4,768 women of reproductive age in Tanzania, 497 (10.4%) had CS. Attaining primary (Adjusted Odds Ratio (aOR): 1.79,95% CI 1.23–2.60), secondary (aOR:2.07,95% CI 1.36–3.14) and higher education (aOR: 2.35, 95% CI 1.08–5.12); having a husband/partner with higher education; being in richest household wealth quintile (aOR:1.98,95% CI (1.31-3.00), having a job (aOR:1.29, 95% CI: 1.05–1.58 and having attended more than 4 antenatal care (ANC) visits (aOR: 1.36, 95% CI: 1.11–1.67) were associated with a higher odds of undergoing CS compared to their respective counterparts. However, living in rural areas (aOR: 0.74, 95% CI:0.58–0.94), being multiparous women with 2–4 births (aOR: 0.67, 95% CI: 0.53–0.84) and 5 or more births (aOR: 0.44, 95% CI: 0.32–0.60) were associated with lower odds of CS. Conclusion The overall prevalence of CS among women of reproductive age in Tanzania was 10.4%. The highest educational level, husband/partner’s educational attainment, household wealth quintile, type of residence, employment status, increased ANC number, and high parity were associated with CS. The CS prevalence is at the lower limit of the recommendation of the World Health Organisation of 10–15%. Further researches are necessary to highlight other barriers, facilitators and outcome of CSs in Tanzania to advise policy stakeholders. Prevalence and factors associated with caesarean section among Tanzanian women of reproductive age: evidence from the 2022 Tanzania demographic and health survey data Bonfils Nahayo1,2,3* , Gbenga Olorunfemi4 , Samuel Ndayishimye1,3 and Charles Nsanzabera5 http://creativecommons.org/licenses/by-nc-nd/4.0/ http://creativecommons.org/licenses/by-nc-nd/4.0/ https://orcid.org/0009-0004-1485-8873 https://orcid.org/0000-0001-6634-8550 https://orcid.org/0009-0008-3110-1628 https://orcid.org/0000-0003-2926-5558 http://crossmark.crossref.org/dialog/?doi=10.1186/s12889-025-21967-2&domain=pdf&date_stamp=2025-2-25 Page 2 of 6Nahayo et al. BMC Public Health (2025) 25:794 Background As opposed to traditional vaginal delivery, cesarean sec- tion (CS) has been on an increasing trend globally at a rate of 4.4% annually with notable increases in Eastern Europe and Asia [1]. Cesarean deliveries (CS) are pro- jected to rise to 28.5% globally by 2030 [2]. According to a study conducted by Igwemadu et al., about 25% of all deliveries in many countries were by CS [3]. CS is often preferred over vaginal delivery due to the perception of it being painless and safer [4]. It is a medical interven- tion that is invaluable in saving the life of mothers and babies before or during labour in selected cases [5]. How- ever, the World Health Organization (WHO) has set an acceptable limit of 15% for CS deliveries [6, 7]in order to mitigate health risks associated with the procedure such as postoperative infections complications causing mor- bidity and mortality [8]. The adoption rate of CS in Africa was slow, with West and Central Africa being the last to adopt the process with 3% in 2000 to 4.1% in 2015 [9]. In Burkina Faso, CS was as low as 2%. In order to encourage more women who needed to carry out the procedure, a no cost policy was established back in 2016 [10]. An evidence of growth in adoption of cesarean section in a study conducted in Rwanda stated that the rate of cesarean section increased from 2.2% in 2000 to 15.6% in 2019/20 [11]. However, unnecessary utilization of the cesarean section procedure has adverse health effects on the mother, the child, or both [12, 13]. Currently, cesarean section in Sub-Saharan Africa is rising at an alarming rate and unfortunately, 1 out of every 100 women dies after cesarean Sect. [14]. Despite this, the benefits of the procedure cannot be overemphasized. The indications for CS includes previous Cesarean Section, fetal distress, prolonged labor, failed induction, and malpresentation/ malposition [15]. Other associated factors includes poor socioeconomic status, lower den- sity of obstetricians, and lower density of hospital beds [16]. Furthermore, regional, cultural preferences, social norms, the pregnant women’s attitudes toward cesar- ean section and obstetricians’ beliefs or attitudes toward cesarean section can impact on the prevalence of CS in a region [17]. Another study identified factors affect- ing cesarean section rates to include; bad experience of previous vaginal delivery, a lack of information about the adverse outcomes after a cesarean section, child bad delivery position, mothers’ underlying medical condition, reduction in perinatal mortality and neonatal morbidity, twin pregnancy, fear of vaginal delivery and misconcep- tions about the superiority [18]. Fetal presentation, and uterine dynamics, at the time of admission, were evidently associated with cesarean Sect. [19]. Complication such as dystocia, foetal distress, breach births, post-term pregnancy, multiple pregnancy, and pregnancy-induced hypertension are other reasons why cesarean section is favoured over vaginal delivery [20]. Region of residence, type of place of residence, cou- ples’ level of education, wealth index, year of birth, previ- ous terminated pregnancy, use of contraception, size of child, mother’s age at first birth, preceding birth interval and Hepatitis B vaccination or infection, Human immu- nodeficiency virus infection also influences cesarean delivery rates [21]. In Tanzania, the CS deliveries rates was 28.9% in a ter- tiary hospital with 29,752 singleton deliveries [22]. In Tanzania, the percentage of women having cesarean sec- tions increased from 2% in 1996 to 6% in 2015–16. The same study showed that women in urban regions con- tinued to have a greater rate of CSs than women in rural areas, and this difference grew with time [23]. There are paucity of studies on the current prevalence and factors influencing CS rates in Tanzania. Therefore, this study aims to determine the prevalence and factors associated with CS in Tanzanian women of reproductive age using the latest Demographic and Health survey data. Methods Study sampling and participants Data from the 2022 Tanzania Demographic and Health Survey (DHS) were utilized for this secondary data anal- ysis. From February to July 2022, a population-based cross-sectional study was conducted in Tanzania using a stratified two-stage cluster sampling method. DHS are cross-sectional, nationally representative surveys of households, with women of reproductive age (15–49 years) self-reporting on the use of reproductive and maternal healthcare. A total of 15,705 households were successfully inter- viewed. In the interviewed households, 15,699 women aged 15–49 who were either permanent residents of the selected households or visitors who stayed in the house- hold the night before the survey were interviewed. How- ever, interviews were completed with 15,254 women. Women who underwent CS in the 5 years before the sur- vey were included in the analysis. Outcome variable The outcome variable was delivery by CS, which was cat- egorized into “Yes” or “No”. Women who underwent CS were coded as 1 and their counterpart who didn’t were coded as 0. Keywords CS, Women, Reproductive age, Tanzania Page 3 of 6Nahayo et al. BMC Public Health (2025) 25:794 Explanatory variables Previous research on cesarean sections served as the basis for the selection of the independent factors [11, 24, 25]. Socio-demographic factors and other characteristics were included in the following explanatory variables. Age was recoded into three age groups (15–19,20–34,35–49) and marital status with two response options (married, living with partner). About highest educational level for our respondents and husband/partner level, four levels were considered (no education, primary, secondary, and higher education). We have also household wealth quin- tile (poorest, poorer, middle, richer, and richest), type of residence (rural, urban) and employment status (not working, working). Number of Antenatal care (ANC) vis- its was grouped into two categories (< 4, ≥ 4) and parity was grouped into three (1,2–4, ≥ 5). Data analysis Analysis was done using SPSS version 25 statistical soft- ware (IBM SPSS Statistics). Frequencies and percentages were computed to describe the demographic characteris- tics of respondents and outcome variable. Binary and multivariable logistic regression analyses were performed to examine the existence of a relation- ship between CS and the independent variables. Bivariate analysis was conducted for all the independent variables against the outcome variable determining their odds ratio (OR) and P-value. All independent variables that were statistically significant at P-value < 0.05 in the bivari- ate analysis were entered for multivariable binary logis- tic regression analysis. The crude odds ratios (COR) and adjusted odds ratios (aOR) with their accompanying 95% confidence intervals (32). Variables that had a P-value < 0.05 at multivariable analysis were considered as significant factors associated with caesarean among reproductive age women (15–49 years). The results were presented in the form of text and tables. The goodness of fit of the final model was tested by Hosmer-Lemeshow p-value > 0.05. Results A total of 4,768 participants were included in this study (Table  1). The majority were 20–34 years old (69.3%), married (72.1%), living in rural area and working (59.4%). Additionally, 51.4% attained a primary level of education, 58.2% had attended less than 4 ANC and 52.2% parity of 2–4 children. Moreover, 56.1% had Husband/partner’s with primary education and 21.2% were in the poorest category. The overall prevalence of CS was 10.4% among women of reproductive age in Tanzania. A bivariate analysis in Table  2. Indicates that high- est educational level, husband/partner’s education level, household wealth quintile, type of residence, employ- ment status, number of ANC and parity were associated with CS. The factors associated with CS are shown in Table  3. Women with primary (aOR: 1.79,95% CI 1.23–2.60), sec- ondary (aOR: 2.07,95% CI 1.36–3.14) and higher educa- tion (aOR: 2.35, 95% CI 1.08–5.12) had higher odds of CS compared to the women without education. Women whose husband/partner attained higher education had 87% higher odds of CS compared to the women whose husband/partner had no education. In terms of economic factors, women in richer house- hold wealth quintile (aOR:1.98,95% CI (1.31-3.00) and those in middle (aOR:1.91,95% CI (1.28–2.85) had 1.9 times higher odds of CS compared to the women in the poorest household wealth quintile. Moreover, women in the richest category have a 2.8 greater odds of hav- ing a CS than the women in the poorest household wealth quintile. Odds of CS were 26% lower for women living in rural area compared to the women living in urban area (aOR: 0.74, 95% CI:0.58–0.94). Moreover, women who were working (aOR:1.29, 95% CI: 1.05–1.58) had 29% higher odds of CS than those who had no job. Table 1 Socio-demographic and reproductive characteristics of the study participants Variables Frequency Per- centageN = 4,768 Age 15–19 295 6.2 20–34 3302 69.3 35–49 1171 24.6 Marital status Married 3439 72.1 Living with partner 1329 27.9 Highest educa- tional level No education 995 20.9 Primary 2449 51.4 Secondary 1273 26.7 Higher 51 1.1 Husband/part- ner’s education level No education 666 14.0 Primary 2676 56.1 Secondary 1208 25.3 Higher 147 3.1 Don’t know 71 1.5 Household wealth quintile Poorest 1010 21.2 Poorer 938 19.7 Middle 940 19.7 Richer 961 20.2 Richest 919 19.3 Type of residence Urban 1278 26.8 Rural 3490 73.2 Working status Not working 1938 40.6 Working 2830 59.4 Number of ANC < 4 2775 58.2 ≥ 4 1993 41.8 Parity 1 871 18.3 2–4 2489 52.2 ≥ 5 1408 29.5 Page 4 of 6Nahayo et al. BMC Public Health (2025) 25:794 Additionally, women who attended more than 4 ANC had 36% higher chance of CS compared to their counter- parts who attended fewer than 4 ANC (aOR: 1.36, 95% CI: 1.11–1.67). About parity, multiparous women with 2–4 births (aOR: 0.67, 95% CI: 0.53–0.84),5 and more (aOR: 0.44, 95% CI: 0.32–0.60) had respectively 33% and 56% lesser odds of CS compared to primiparous. However, the age and marital status were not associated with CS. Discussion Our research revealed that the nationwide prevalence of CS in Tanzania is 10.4%, which may indicate a low level of service utilization of CS in the nation. Almost similar CS prevalence (11.4%) was reported in a study conducted in Ghana [26]. The CS rate in Tanzania is at the lower bor- der of the WHO recommendation of CS rates of 10–15% [27]. This may suggest either that some women that will benefit from the procedure are not being offered or there are not enough health personnel or facilities for the procedure in Tanzania. This is a strong possibility con- sidering the fact that CS rates is as high as 30% in high resource settings such as the United States of America [28]. The higher the level of educational attainment among women, the more likely they are to opt for a CS. Our findings were in line with a study conducted in Nigeria which revealed that CS in prevalence was comparatively higher in women who had acquired at least a secondary level of education (4.8%), and in rich households (4.5%). This can be explained by limited access to antenatal care and a lack of knowledge about childbirth options. Never- theless, women with secondary or higher education had a lower risk of CS delivery, according to a study done in northern Ghana with a smaller sample size [29]. Our findings indicated that women in richer household wealth quintile (aOR:1.98,95% CI (1.31-3.00) and those in middle (aOR:1.91,95% CI (1.28–2.85) had 1.9 times higher odds of CS compared to the women in the poor- est household wealth quintile. These findings align with a study conducted by Islam et al. in Sub-Saharan Africa, which reported that more women with formal educa- tion and from higher socioeconomic classes had CSs as Table 2 Association between socio-demographic and reproductive characteristics and caesarean section Variables OR [95% CI] CS P- ValueNo (%) Yes (%) Age 15–19 1.00 264(89.5) 31(10.5) 1.00 20–34 0.95[0.65–1.40] 2970(89.9) 332(10.1) 0.804 35–49 1.10[0.73–1.66] 1037(88.6) 134(11.4) 0.65 Marital status Married 1.00 3081(89.6) 358(10.4) 1.00 Living with partner 1.01[0.82–1.24] 1190(89.5) 139(10.5) 0.96 Highest educa- tional level No education 1.00 957(96.2) 38(3.8) 1.00 Primary 2.56[1.80–3.64] 2223(90.8) 226(9.2) < 0.001 Secondary 5.12[3.59–7.30] 1058(83.1) 215(16.9) < 0.001 Higher 13.74[7.10- 26.56] 33(64.7) 18(35.3) < 0.001 Hus- band/ part- ner’s educa- tion level No education 1.00 631(94.7) 35(5.3) 1.00 Primary 1.65[1.14–2.38] 2452(91.6) 224(8.4) 0.008 Secondary 3.18[2.18–4.62] 1027(85.0) 181(15.0) < 0.001 Higher 9.01[5.56– 14.61] 98(66.7) 49(33.3) < 0.001 Don’t know 2.29[1.02–5.15] 63(88.7) 8(11.3) 0.045 House- hold wealth quintile Poorest 1.00 969(95.9) 41(4.1) 1.00 Poorer 1.56[1.03–2.35] 880(93.8) 58(6.2) 0.034 Middle 2.41[1.64–3.53] 853(90.7) 87(9.3) < 0.001 Richer 3.15[2.18–4.56] 848(88.2) 113(11.8) < 0.001 Richest 6.49[4.57–9.21] 721(78.5) 198(21.5) < 0.001 Type of resi- dence Urban 1.00 1048(82.0) 230(18.0) 1.00 Rural 0.38[0.31–0.46] 3223(92.3) 267(7.7) < 0.001 Em- ploy- ment Not working 1.00 1759(90.8) 179(9.2) 1.00 Working 1.24[1.03–1.51] 2512(88.8) 318(11.2) 0.027 Num- ber of ANC < 4 1.00 2564(92.4) 211(7.6) 1.00 ≥ 4 2.04[1.69–2.46] 1707(85.6) 286(14.4) < 0.001 Parity 1 1.00 724(83.1) 147(16.9) 1.00 2–4 0.61[0.49–0.76] 2214(89.0) 275(11.0) < 0.001 ≥ 5 0.28[0.21–0.37] 1333(94.7) 75(5.3) < 0.001 Table 3 Multivariate logistic regression of the factors associated with caesarean section in Tanzania Variables AOR P-Value 95% CI Highest educa- tional level No education 1.00 1.00 1.00 Primary 1.79 0.002 [1.23–2.60] Secondary 2.07 0.001 [1.36–3.14] Higher 2.35 0.032 [1.08–5.12] Husband/part- ner’s education level No education 1.00 1.00 1.00 Primary 0.91 0.647 [0.61–1.35] Secondary 0.94 0.785 [0.61–1.46] Higher 1.87 0.035 [1.04–3.35] Don’t know 0.87 0.757 [0.37–2.04] Household wealth quintile Poorest 1.00 1.00 1.00 Poorer 1.4 0.116 [0.92–2.12] Middle 1.91 0.002 [1.28–2.85] Richer 1.98 0.001 [1.31-3.00] Richest 2.82 < 0.001 [1.79–4.42] Type of residence Urban 1.00 1.00 1.00 Rural 0.74 0.015 [0.58–0.94] Employment Not working 1.00 1.00 1.00 Working 1.29 0.015 [1.05–1.58] Number of ANC visits < 4 1.00 1.00 1.00 ≥ 4 1.36 0.003 [1.11–1.67] Parity 1 1.00 1.00 1.00 2–4 0.67 0.001 [0.53–0.84] ≥ 5 0.44 < 0.001 [0.32–0.60] Page 5 of 6Nahayo et al. BMC Public Health (2025) 25:794 compared to women from lower socioeconomic classes [25]. Similar results were found in Ghana, where the CS rate increased in tandem with women’s increasing wealth level [30]. This may be due to the fact that people with a higher standard of living often have easier access to qual- ity antenatal care. This can make it possible to detect and manage possible complications of pregnancy more effec- tively, and to have recourse to a CS if necessary. We found that Odds of CS were 26% lower for women living in rural areas compared to the women living in urban areas (aOR: 0.74, 95% CI:0.58–0.94). Similar results were found in a study conducted in Nigeria, where women living in urban residence had higher odds of CS than those living in rural areas [24].Other studies indi- cated that people from urban environments are more likely to use C-section deliveries, while people from rural locations use them less frequently [25, 26]. Cesarean sec- tions are performed in hospitals, and there are few hospi- tals in rural areas. Referral fees and transportation to the hospitals where the C-section is performed could also be factors in the underutilization for women living in rural environments. In our study, women who attended more than 4 ANC had 36% higher chance of CS compared to their coun- terparts who attended fewer than 4 ANC (aOR: 1.36, 95% CI: 1.11–1.67). A study performed in Brazil showed that increased prenatal visits and cesarean sections were found to be statistically significantly correlated [31]. Multiparous women with 2–4 births (aOR: 0.67, 95% CI: 0.53–0.84), 5 and more (aOR: 0.44, 95% CI: 0.32– 0.60) had respectively 33% and 56% lesser odds of CS compared to primiparous. This is consistent with the results of a study in Nigeria, primiparous women had an increased proportion and yet at more risk of CS delivery compared to multiparous [32]. It was also in line with a retrospective cohort study (2000–2015) conducted in Tanzania, primiparous women were more likely to give birth by CS [32]. That can be explained that oftentimes, first-time mothers have smaller pelvic dimensions, which can complicate the baby’s passage down the birth canal. Strength and limitations The use of DHS dataset, which used a validated question- naire of DHS MEASURE, was the strength of the study. It is also a national wide representative survey. How- ever, the use of a cross sectional study design that cannot describe cause and effect relationship of variables was the limitation of the study. Conclusion Our study discovered that the prevalence of cesarean sec- tion was 10.4% in Tanzania. There was a strong associa- tion found between CS and the following factors: highest educational level, husband/partner’s education level, household wealth quintile, type of residence, employment status, number of ANC and parity. The CS prevalence of Tanzania is at the lower limit of the recommendation of the World Health Organization of 10–15%. This may sug- gest that some women that needed the procedure were not offered or did not have access to it, thereby leading to increased perinatal morbidity and mortality. Further researches are necessary to highlight other barriers, facil- itators and outcome of CSs in Tanzania to advise policy stakeholders. Abbreviations ANC Antenatal care aOR Adjusted odd ratio CI Confidential Interval CS Cesarean section OR Odd ratio Acknowledgements The authors express gratitude to the management of DHS program for granting us the permission to use Tanzania demographic health and survey data. We also thank teaching and non-teaching staffs of the Pan African University, Life and Earth Sciences Institute (Including Health and Agriculture) for the support. Author contributions BN conceptualized and designed the study, analyzed the data, interpreted the findings, and wrote the manuscript. SN, GB and CN provided guidance on concept development, data analysis, and final manuscript development. The final manuscript was read and approved by all authors. Funding The study was not funded. Data availability Data are available upon request from the Demographic and Health Surveys portal: h t t p s : / / w w w . d h s p r o g r a m . c o m / d a t a / d a t a s e t _ a d m i n / l o g i n _ m a i n . c f m Declarations Ethical approval This study utilized secondary data, and ethical considerations did not require specific approval. However, the authorization to access and use the datasets was granted by the DHS program management. Consent for publication Not applicable. Competing interests The authors declare no competing interests. Author details 1Reproductive Health Program, Pan African University Life and Earth Sciences Institute (Including Health and Agriculture) PAULESI, Ibadan, Nigeria 2Université Sagesse d’Afrique, Bujumbura, Burundi 3Department of Obstetrics and Gynaecology, University College Hospital, University of Ibadan, Ibadan, Nigeria 4Division of Epidemiology and Biostatistics, University of Witwatersrand, Johannesburg, South Africa 5African Institute of Research for Public Health and Development, Kigali, Rwanda Received: 10 January 2024 / Accepted: 14 February 2025 https://www.dhsprogram.com/data/dataset_admin/login_main.cfm Page 6 of 6Nahayo et al. BMC Public Health (2025) 25:794 References 1. Ganeriwal SA, Ryan GA, Purandare NC, Purandare CN. ‘Examining the role and relevance of the critical analysis and comparison of cesarean section rates in a changing world’, Taiwan. J. Obstet. 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Publisher’s note Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. https://doi.org/10.1016/j.tjog.2020.11.004 https://doi.org/10.1177/17455057221101071 https://doi.org/10.1136/bmjopen-2021-055241 https://doi.org/10.1186/s12916-019-1320-y https://doi.org/10.1186/s12916-019-1320-y https://doi.org/10.1136/bmjopen-2018-027273 https://doi.org/10.1136/bmjopen-2018-027273 https://apps.who.int/iris/bitstream/handle/10665/275377/9789241550338-eng.pdf?ua1 https://apps.who.int/iris/bitstream/handle/10665/275377/9789241550338-eng.pdf?ua1 https://doi.org/10.1111/j.1365-3016.2007.00786.x https://doi.org/10.1186/s12939-019-1063-6 Prevalence and factors associated with caesarean section among Tanzanian women of reproductive age: evidence from the 2022 Tanzania demographic and health survey data Abstract Background Methods Study sampling and participants Outcome variable Explanatory variables Data analysis Results Discussion Strength and limitations Conclusion References