Cesarean Section Overuse, Clinical Decision-Making, and Patient Trust in Somalia’s Predominantly Private Maternal Health System: A Commentary on Quality, Equity, and the Human Experience of Birth

Abstract: Cesarean section is an essential obstetric intervention when clinically indicated, but global rates have risen markedly, raising concerns about overuse, inequities, and misaligned incentives in some settings. Somalia represents a fragile health system context in which cesarean decision-making occurs within a predominantly private maternity sector shaped by variable governance, uneven intrapartum monitoring capacity, and high out-of-pocket costs. This commentary synthesizes published literature and institutional reports, together with contextual clinical experience, to examine drivers of cesarean escalation, community perceptions of decision-making, and the implications for trust, autonomy, respectful care, and equity. It argues that improving childbirth outcomes in Somalia requires a balanced approach that protects timely access to life-saving cesarean section while reducing avoidable surgery through better documentation, clearer communication, strengthened intrapartum assessment, and feasible quality-improvement measures. Keywords: cesarean section, maternal health, obstetric decision-making, private health facilities, Somalia, quality of care, CTG interpretation, respectful maternity care