Determinants and Prevalence of Cesarean Section in River Nile State, Sudan: A Cross-Sectional Study

Both Western and non-Western literature have documented the caesarean section from ancient times. Mythology obscures the term’s early history, despite the fact that it was originally used in obstetrics in the seventeenth century. Though it seems odd given that Julius Caesar’s mother Aurelia Cotta survived for many years later, the name “caesarean” is said to have originated from his birth. In the past, it was only done in an effort to save the fetus when the mom was dead or near death. This was the general trend up to the nineteenth-century advent of anesthesia. Throughout the twentieth century, advancements in surgical skill from the late nineteenth century have improved the process, leading to reduced morbidity and mortality. Thus, the goals of a caesarean section have changed from saving the fetus or for cultural or religious reasons to thinking about the woman’s wishes and the safety of the mother and child [1].

Caesarean Sections (CS) were first performed in the 600s, before the century, when the abdomens of dying women were cut open to save a fetus prior to burying it with its mother. By the early 21st century, CS rates were increasing above an ideal rate [2]. The first modern Caesarean section was performed by German gynecologist Ferdinand Adolf Kehrer in 1881 [3].

During a caesarean section, a woman’s abdomen (laparotomy) and uterus (hysterotomy) are cut in order to give birth to one or more infants. Nowadays, between 25% and 30% of infants born in the UK are delivered by Caesarean section. Ensuring that mothers and babies who require cesarean birth receive it and that those who do not are spared needless intervention should be our primary goals [4].

A century ago, the current cesarean birth technique was introduced with the goal of lowering complications, morbidity, and death rates for both mothers and infants. Sadly, though, certain communities increasingly view cesarean sections as luxuries, and they are not only performed when absolutely essential to preserve the mother and child. The World Health Organization publications suggest that the predicted rate of cesarean birth should be as low as 15%, which is supported by practically all scientific resources [5].

The optimal rate for cesarean sections is between 10% and 15%, according to the World Health Organization [WHO] (2015). Nonetheless, both in industrialized and developing nations, cesarean sections have grown more frequent over time. just like with any surgery, Caesarean sections include short- and long-term risks, which can last for many years after the current birth and have an impact on the woman’s health, the health of the newborn, and future pregnancies [6].

According to a study, local economic levels do have an impact on the incidence of Caesarean sections. The national rate of cesarean sections was found to vary from South Sudan’s 0.6% and the Dominican Republic’s 58.9% [7]. Over a decade, CS rates in Sudan increased steadily from 4.3% in 2006 to 6.7% in 2010 and 9.1% in 2014. During this period, CS rates varied considerably across regions showing higher rates in the Northern region (7-25%) and lower rates in Darfur (2-3%). Urban areas experienced rapidly increasing rates (6-14%), while rural areas showed negligible changes to absolute CS rates over time (5-7%). We also found geographic regions; maternal age, maternal education, receiving antenatal care, and birth order of the child were important determinants of CS in Sudan [8]. A study that was conducted in Kassala, Eastern Sudan, between December 2014 and March 2015 and published on July 1, 2016, states that the current study’s cesarean delivery rate in Kassala is 17.8%. Older women, primipare women, and women with medical disorders were found to be more likely to give birth via caesarean [9].

Once again in Sudan A hospital-based cross-sectional study was carried out at Khartoum Hospital from October to December 2011 and published in 2013. The study’s conclusions included the need to adopt measures like increasing the rate of instrumental delivery and allowing primigravidae to try labor before giving birth in order to lower the hospital’s high cesarean delivery rate [10]. The prevalence of caesarean sections in emerging nations has been said to be high and is still growing. Guidelines and suggestions haven’t really had much of an influence on reducing this rise. There’s no reason why any location should have more than 10-15% more cesarean sections performed than any other, according to a 1985 research group report that the World Health Organization organized. The average cesarean rate in the majority of developed nations currently surpasses 20%, despite the fact that 10-15% rates were considered high but okay at the time. So, we in this study focus on if Caesarean Sections rate has increased in River Nile state and what the predisposing factors for that increase, despite the recommendations of the World Health Organization

General objective

To estimate the rate and predisposing factors of C-sections at river Nile state 2024.

Specific objectives

1) To determine Caesarean Section Rate in River Nile state
2) To establish the predisposing factors of Caesarean Section delivery in River Nile state

Study design

The design was a Descriptive Cross-sectional study

Study area

River Nile State: One of the 18 states of Sudan. It has an area of 122,123 km² (47,152 mi²) and an estimated population of 1,472,257 (2017). It is made up of seven localities: Ad-Damir (Capital), Atbara, Shendi, Berber, Abu Hamed, El Matamah, El Buhaira.

Study setting

Teaching hospitals in River Nile State

Study duration

The Duration of Study is 12 months and done between July 2023 and august 2024

Study population

Pregnant women from river state that admitted to the maternity ward of this hospitals at 2023/24 and undergo to C.S

Sample size

The formula for calculation of sample size:
Z= 1.96 constant
P= prevalence =16% =0.16
Q=1-p = 0.84
D =degree of error =0.05
Result =206
With addition 10% of total population (non-response rate) =20
End result (sample size) =226

Sampling technique

A Simple random technique was used to identify the respondent mothers. All mothers who met the inclusion criteria were assigned a random number.

Data collection techniques

The following tools were used; Interview and structured questionnaires. Document Review Guide was used to guide and extract information, throughout 12 months, on the numbers of Caesarean Sections conducted, total number of deliveries conducted. Lastly, the researcher to record individual responses from the mothers used structured self-administered questionnaire.

Caesarean Section Delivery Rate, which is the total number of resident caesarean deliveries among woman (P1) divided by the total number of all deliveries for the specified hospital during a specified time period (P2), was computed. The study found the CSR for River Nile State was 49.7 %.

To determine the average CSR, data was collected for the past year from august 2023 to July 2024; use data information from Federal Ministry of Health (Sudan) Nile River State (Table 1).

Table 1:Data Used for Computing CSR.

Caesarean Section Rate (CSR) =

Cesarean section Rate in River Nile State compared to WHO recommendations and other regions the Cesarean Section Rate (CSR) in River Nile State is remarkably high at 49.7%, more than three times the World Health Organization’s recommended range of 10-15%. This elevated CSR underscores a widespread trend of rising CS rates globally and within Sudan. For instance, Abdel- Rahman et al. [8] documented a similar trajectory in Sudan, where national CSR rose from 4.3% in 2006 to 9.1% in 2014. Their study also reported marked regional differences, with higher rates in urbanized northern areas (7-25%) compared to 2-3% in Darfur’s rural regions [8]. The high CSR in River Nile, primarily among urban populations, aligns with trends observed in a 2024 metaanalysis of Eastern Africa, which reported CS rates exceeding WHO recommendations across the region, particularly in urban and economically advantaged areas (p < 0.001) [11].

The reliance on planned (scheduled or Elective) CS (65.5% of cases) as opposed to emergency CS (34.5%) highlights the influence of scheduling convenience and medical guidance in deciding the delivery method. A similar finding was reported in South Africa, where high CS rates in private healthcare settings were attributed to socioeconomic factors and clinician preferences [12]. These findings collectively raise questions about the necessity of CS as a standard approach and suggest an underlying pattern in both local and broader contexts where socioeconomic factors and healthcare infrastructure heavily influence delivery decisions.

In conclusion, this study revealed an alarmingly high cesarean section rate of 49.7% in River Nile State, Sudan, exceeding the recommended global standards. Planned CS constituted the majority of cases, and key predictors included previous CS, provider recommendation, rural residence, and moderate socioeconomic status. The influence of healthcare professionals on delivery mode decisions was substantial. The findings suggest a pressing need to evaluate clinical practices, improve emergency obstetric services and promote informed maternal choice. By addressing the factors driving this trend and through comprehensive education and policy reforms, it is possible to reduce unnecessary cesarean deliveries and promote safer childbirth practices in the region.

This study lays the groundwork for future research and interventions aimed at understanding and mitigating the high rates of cesarean sections, ensuring that every delivery prioritizes the health and well-being of both mother and child. Future research should focus on exploring cultural, psychological, and economic factors influencing the decision for cesarean sections, especially in regions with rapidly rising rates. Additionally, qualitative studies could provide deeper insights into patient and provider attitudes toward childbirth options, helping to design more effective educational programs and intervention strategies. Ultimately, the goal should be to align cesarean section rates with global recommendations while ensuring that every woman has access to safe, high-quality obstetric care, whether for vaginal or cesarean delivery. This will not only help reduce unnecessary surgeries but also improve overall maternal and neonatal health outcomes, creating a more sustainable healthcare system in River Nile State and beyond. By building on the findings of this study and addressing the highlighted challenges, it is possible to achieve a more balanced and evidence-based approach to childbirth, one that prioritizes the health and preferences of women while minimizing the risks associated with unnecessary cesarean sections.

1. Todman D (2007) A history of caesarean section: From ancient world to the modern era. Aust N Z J Obstet Gynaecol 47(5): 357-361.
2. Fadhl NN, Zubair OA, Al-wazzan RM (2020) Prevalence of caesarean sections in Mosul city hospitals: A cross - sectional study. Ann Coll Med Mosul 42(2): 126-132.
3. Ritter J (2012) The modern-day C-section history of the caesarean. Mod C-section 159-167.
4. Murphy DJ (2017) Operaive delivery. In: Kenny L, Myers J (Eds.), Obstetrics by ten teachers (20^th edn), CRC Press Taylor& Francis group, Boca Raton, Florida, USA, pp. 245-254.
5. Rafiei M, Saei M, Naz G, Akbari M, Kiani F, et al. (2018) Prevalence, causes, and complications of cesarean delivery in Iran: A systematic review and meta- analysis. Int J Reprod Biomed 16(4): 221-234.
6. WHO statement on caesarean section rates (2015) (WHO/ RHR/15.02).
7. Boatin AA, Schlotheuber A, Betran AP, Moller AB, Barros AJD, et al. (2018) Within country inequalities in caesarean section rates: observational study of 72 low and middle income countries. BMJ 360: k55.
8. Abdel-Rahman ME, Thalib L, Rayis DA (2022) Caesarean section in Sudan: Findings from nationwide household surveys on rates, trends, and geographic and sociodemographic variability. BMC Pregnancy Childbirth 22(1): 716.
9. Elmugabil A, Rayis DA, Hassan AA, Ali AA, Adam I (2016) Epidemiology of cesarean delivery in Kassala, Eastern Sudan: A community-based study 2014-2015. Sudan J Med Sci 11(2): 49-54.
10. A Rayis D (2013) An epidemic of cesarean deliveries at khartoum hospital in Sudan with over two-fifths of neonates delivered through the abdomen. J Women’s Health Issues & Care 2(6): 10-13.
11. Tesfaye A, Debebe M, Adugna H, Kassa RT, Deribe LK, et al. (2024) Prevalence and associated factors of caesarean section among mothers who gave birth across Eastern Africa countries: Systematic review and meta-analysis study. Heliyon 10(12): e32511.
12. Yusuf A, Sheik A, Ali M, Hassan H (2023) prevalence of cesarian delivery and associated factors among mothers who gave birth at public hospitals, JIGJIGA, Ethiopia, pp. 1-12.