Caesarean section (CS) is an essential intervention in modern obstetrics that can prevent maternal and neonatal deaths when performed for appropriate medical indications [1] [2] . Over recent decades, CS rates have increased markedly worldwide, with the WHO estimating a nearly threefold rise in global rates, although this increase varies widely between and within countries [3] [4] . While elective CS has become more common in high-income settings [5] , emergency CS continues to predominate in sub-Saharan Africa, where delays in decision-making, inadequate resources, and limited skilled staff contribute to poor outcomes [6] .

Across Africa, CS rates increased from 5.4% in 2004 to 21.2% in 2018 [7] ; in Cameroon, rates rose from 9.8% (2000-2010) to 14.7% (2010-2019) [8] . Despite improvements in obstetric and anesthetic techniques, maternal complications following CS remain high, at 10.3% in Morocco [9] and up to 40.55% in Guinea [10] . The rate of CS in health facilities serves as a proxy for access to essential obstetric care and can inform policymakers monitoring maternal and child health services [11] . According to the 2023-2024 Demographic and Health Survey (DHS) of the DRC, the CS rate in North Kivu Province reached 20.9%, exceeding the WHO benchmark of 15% [12] .

This study, therefore, aimed to describe the frequency and maternal-fetal outcomes of cesarean deliveries in eight rural health zones of North Kivu Province, eastern DRC, between 2017 and 2023.

The frequency of CS observed (37% - 43%) far exceeds the WHO’s recommended threshold of 15% for district hospitals [13] .

These results contrast with those reported in the literature. Overall, in developing countries, the frequency of caesarean section is higher in urban areas than in rural settings [14] [15] . Several factors explain this difference, including the fact that urban areas have better access to emergency obstetric care compared to rural regions [16] .

Such elevated rates in rural North Kivu may be linked to subsidized deliveries in certain facilities and differences in technical capacity and service organization.

Maternal mortality was higher among CS deliveries, consistent with findings from Morocco [17] [18] and Brazil [19] , where similar trends were observed. Except for the Masereka Health Zone, all other zones included in the study exhibited triple-digit maternal mortality rates. This indicates that maternal health outcomes in these areas remain far from the targets set by Sustainable Development Goal 3 (SDG 3). According to this goal, the global maternal mortality ratio should be reduced to double-digit levels—specifically, fewer than 70 deaths per 100,000 live births—by 2030. [20]

In rural DRC, emergency obstetric care faces persistent challenges, including resource constraints, delayed referrals, limited surgical capacity, and sociocultural barriers [21] [22] .

Likewise, neonatal deaths were more frequent after CS, corroborating findings by Ghahiri [23] . In contrast, developed countries have experienced a decline in perinatal mortality despite increasing CS rates [24] . In our context, many CS procedures are performed late and as emergencies following failed vaginal delivery attempts, often due to cultural expectations surrounding “natural” childbirth [25] . Poor prenatal care coverage, inadequate referral mechanisms, and limited neonatal care infrastructure exacerbate these outcomes [26] .

The predominance of absolute indications such as uterine scar, cephalopelvic disproportion, and fetal distress reflects delays in the detection and referral of high-risk pregnancies [27] [28] .

This study provides rare insight into CS rates and outcomes in rural areas of North Kivu Province. The archiving service is rudimentary in the healthcare establishments targeted by this study. The use of secondary data limited the ability to explore some clinical and sociodemographic determinants in detail.

The rate of caesarean deliveries in rural North Kivu is excessively high and is associated with elevated maternal and neonatal mortality. Further analytical studies are needed to identify the factors contributing to this trend and to strengthen health system capacity for the safer and more judicious use of CS in rural DRC.

All authors made substantial contributions to the conception, data collection, analysis, and drafting of this manuscript and approved the final version.