Women's caesarean section preferences: A multicountry cross-sectional survey in low- and middle-income countries

•Among women at low risk of caesarean section, the preference for this delivery mode is low although caesarean section rates are high in the study hospitals.•Nulliparous women who had never given birth were more likely to prefer caesarean section than women with previous childbirth experience.•Preference for caesarean section is based on the fear of labour pain, which requires providing support to women during pregnancy and ensuring access to adequate analgesia during labour and childbirth.•Interventions must be encouraged in order to support women's preference and to provide evidence-based information to enable women to choose the most appropriate mode of delivery. To measure the proportion of women's preferences for CS in hospitals with high caesarean section rates and to identify related factors. A cross-sectional hospital-based postpartum survey was conducted. We used multilevel multivariate logistic regression and probit models to analyse the association between women's caesarean section preferences and maternal characteristics. Probit models take into account selection bias while excluding women who had no preference. Thirty-two hospitals in Argentina, Thailand, Vietnam and Burkina Faso were selected. A total of 1,979 post-partum women with no potential medical need for caesarean section were included among a representative sample of women who delivered at each of the participating facilities during the data collection period. The overall caesarean section rate was 23.3 %. Among women who declared a preference in late pregnancy, 9 % preferred caesarean section, ranging from 1.8 % in Burkina Faso to 17.8 % in Thailand. Primiparous women were more likely to prefer a caesarean section than multiparous women (β=+0.16 [+0.01; +0.31]; p = 0.04). Among women who preferred caesarean section, doctors were frequently cited as the main influencers, and “avoid pain in labour” was the most common perceived benefit of caesarean section. Our results suggest that a high proportion of women prefer vaginal birth and highlight that the preference for caesarean section is linked to women's fear of pain and the influence of doctors. These results can inform the development of interventions aimed at supporting women and their preferences, providing them with evidence-based information and changing doctors' behaviour in order to reduce the number of unnecessary caesarean sections. The QUALI-DEC trial is registered on the Current Controlled Trials website (https://www.isrct