Mapping the gendered dynamics of cesarean section: A scoping review

Cesarean section (CS) is a lifesaving obstetric intervention when medically indicated, yet global rates have risen sharply over recent decades, with substantial variation across and within countries. While underuse persists in many low-resource settings, overuse is increasingly documented in higher-income and private-sector facilities, raising concerns about inequitable access, unnecessary surgical intervention, and divergent quality of maternity care. Existing explanations have largely focused on clinical indications and biomedical risk profiles, often neglecting the social and gendered structures that shape decision-making, institutional practice, and access to care. This scoping review examines how gender norms, roles, and power relations influence CS utilization across diverse global contexts. We conducted a scoping review following PRISMA-ScR guidelines, searching PubMed, Scopus, and CINAHL for English- and French-language publications from 2000 to 2025. Studies were included if they explicitly examined gender-related drivers or constraints shaping CS access, decision-making, or delivery practices. A three-concept search strategy captured cesarean delivery, gendered constructs, and mechanisms through which gender operates in health systems and social contexts. Data were extracted using a structured matrix and synthesized thematically through a gender analysis framework spanning access to resources, roles and practices, norms and beliefs, decision-making power, and institutions, while distinguishing between gendered "push" and "pull" factors influencing CS use. 95 studies met inclusion criteria. The evidence demonstrates that CS utilization is shaped by interacting gendered forces operating across individual, household, community, and health system levels. Four interrelated domains emerged. First, political and economic structures-including financing models, privatization, and provider incentives-shape institutional preferences for surgical delivery and normalize medicalized childbirth. Second, clinical cultures marked by medical paternalism, risk aversion, and medico-legal pressures shift decision-making authority from women to providers. Third, household and community gender relations structure reproductive decision-making through spousal authority, familial pressure, and socially embedded norms of motherhood, sexuality, and bodily integrity. Fourth, women's preferences are shaped by both enabling and constraining conditions, including time poverty, fear of labor pain, concerns about sexual and reproductive health, and uneven access to respectful maternity care. Across contexts, CS emerges as both overused and underused depending on women's social position, access to resources, and exposure to institutional power. Wealth, urban residence, and private insurance often facilitate elective CS, while poverty, geographic isolation, and weak health systems restrict access even when clinically necessary. Gendered norms simultaneously construct vaginal birth as morally valued and CS as either a marker of modernity or medical failure, reinforcing contradictory pressures on women and providers alike. This review highlights that CS is not solely a clinical outcome, but a socially produced intervention embedded within gendered systems of power. Addressing inequities in CS requires interventions that extend beyond clinical guidelines to include health financing structures, institutional accountability, provider norms, and the broader social conditions that shape reproductive agency.