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

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.