Health system drivers of caesarean deliveries in south Asia: a scoping review

Caesarean section (CS) rates are rising across south Asia, often without medical indication, posing significant public health concerns. This Review applied a framework-guided evidence synthesis using a scoping review approach, structured by the Socio-Ecological Model (SEM), to examine health system drivers of CS. Seventy-five studies were included, mainly from India, Bangladesh, and Pakistan. At the individual level, maternal education, socioeconomic status, and birth order influenced CS use. Community-level drivers included family preferences and media exposure. At the provider level, decision-making was shaped by financial incentives, medico-legal concerns, and scheduling convenience. Other system-level drivers, such as private sector dominance, limited regulation, and insurance coverage, were associated with increased CS rates. While most findings aligned with the SEM, some extended beyond its scope. The Review highlights the need for coordinated policy responses across levels, including payment reforms, regulatory oversight, and improved antenatal counselling, to ensure CS use aligns with clinical need rather than socio-economic or institutional pressures.