# Cesarean Delivery Trends in Conflict-Affected Settings: Prevalence, Predictors, and Outcomes at a Rural Referral Hospital in Yemen

## TL;DR

This study examines high cesarean delivery rates in a rural Yemeni hospital, finding they exceed WHO recommendations and are driven by factors like prior cesareans and maternal age.

## Contribution

The study provides insights into CD determinants in a conflict-affected, low-resource setting with a focus on rural Yemen.

## Key findings

- The overall cesarean delivery rate was 48.3%, exceeding WHO recommendations.
- Emergency cesareans were strongly linked to fetal distress and hypertension.
- Elective cesareans were associated with advanced maternal age and urban residence.

## Abstract

Background

The global rise in cesarean delivery (CD) rates shows marked disparities between high- and low-resource settings. Yemen's healthcare limitations make understanding CD determinants crucial for maternal and neonatal outcomes. This study examines CD prevalence, predictors, and clinical implications at a rural Yemeni referral hospital.

Materials and methods

We conducted a retrospective analysis of 1,355 delivery records from Jiblah Referral Hospital, Ibb, Yemen, between December 2021 and September 2024. Using IBM SPSS Statistics for Windows, Version 23 (Released 2016; IBM Corp., Armonk, New York, United States), we analyzed CD prevalence and predictors through multivariate logistic regression, examining both overall CD and its elective/emergency subtypes.

Results

The CD rate reached 48.3% (n=654), comprising emergency (40.8%, n=554) and elective (7.4%, n=100) cases. Strongest predictors included prior CD (adjusted odds ratio (aOR): 3.05, 95% confidence interval (CI): 2.18-4.27, p<0.001), women aged 20-30 years (aOR: 1.72, 95% CI: 1.21-2.45), maternal age >30 years (aOR 2.15, 95% CI: 1.46-3.17), urban residence (aOR 1.76, 95% CI: 1.28-2.42), multiparity (aOR 1.87, 95% CI: 1.36-2.56), and breech presentation (aOR 2.56, 95% CI: 1.82-3.60), while literacy showed a protective effect (aOR: 0.72, 95% CI: 0.53-0.98, p=0.036). Emergency CD correlated with fetal distress (aOR 3.02, 95% CI: 2.01-4.54) and hypertension (aOR 2.15, 95% CI: 1.42-3.25), while elective CD associated with advanced maternal age (aOR 2.34, 95% CI: 1.54-3.55) and urban residence (aOR 1.92, 95% CI 1.37-2.69).

Conclusion

This study revealed CD rates more than triple the WHO recommendations, with both emergency and elective procedures showing distinct patterns. Emergency CDs were primarily driven by acute complications like fetal distress, while elective CDs were strongly associated with advanced maternal age and urban residence. The high proportion of emergency procedures particularly highlights challenges in managing obstetric complications, whereas elective cases reflect demographic disparities in access and decision-making. These findings underscore the urgent need for facility-specific audits to reduce unnecessary procedures, enhanced training for obstetric emergencies and vaginal breech delivery, and context-specific research to address both clinical and non-clinical predictors in conflict-affected settings.