Multi-level factors influencing caesarean section preferences among women in low- and middle- income countries: A systematic review

• Understanding the factors influencing women’s preferences for caesarean section (CS) is crucial in LMICs, where overuse can lead to significant health risks. A deeper insight into these preferences can help ensure that CS is used appropriately, improving maternal and neonatal health outcomes. • The review found wide variations in CS preferences across LMICs, ranging from 8.8 % to 58 %. Influencing factors were identified across four levels: individual characteristics, family and healthcare influence, healthcare system factors, and broader socio-cultural norms. • These findings can inform healthcare providers and policymakers in developing strategies that promote appropriate CS use, reduce unnecessary procedures, and support women’s informed decision-making in diverse healthcare settings. Women’s preferences regarding caesarean section (CS) are a significant contributing factor to the increasing and widely varying rates of this procedure across countries and regions. This trend is particularly pronounced in low- and middle-income countries (LMICs), where both overuse and underuse of CS can pose significant health risks. Understanding the multi-level factors influencing CS preferences is essential for promoting the appropriate use of this procedure and ensuring optimal maternal and neonatal health outcomes. To systematically review literature examining multi-level factors influencing CS preferences among women in LMICs through ecological systems and exploring the prevalence of CS preferences. A systematic review was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA). Six electronic databases were searched: Academic Search Ultimate (EBSCO), MEDLINE (EBSCO), Nursing & Allied Health Premium (ProQuest), PubMed, ScienceDirect, and Scopus. The search included studies published from January 2014 to August 2024. The quality of each article was assessed using the Joanna Briggs Institute’s critical appraisal tool. A total of 17 studies were included in this review. The proportion of CS preferences varied significantly, ranging from 8.8 % to 58 % in LMICs. The multi-level factors influencing CS preferences were summarized across four levels, based on ecological systems: microsystem level (sociodemographic factors, reproductive factors, psychological factors, and literacy-related factors), mesosystem level (healthcare influence, family and relative influence), exosystem level (healthcare environment and social media influence), and macrosystem level (socio-cultural factors). Factors within the microsystem, mesosystem, and macrosystem levels displayed the substantial influence aligned with ecological systems. To reduce unnecessary CS, future research should comprehensively explore multi-level factors. Policymakers should implement prominent factors across the system.