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Meta-Analysis
. 2025 Dec 10;15(1):15.
doi: 10.1186/s13643-025-03016-6.

Associations between maternal overweight and obesity with cesarean section delivery in Middle East and North Africa region: a systematic review, meta-analysis, and attributable risk

Basem Al-Omari #  1 , Zufishan Alam #  2 , Joviana Farhat  1 , Salma Abdelrahman Mohamed  3 , Sumyia Mehrin  3 , Linda Östlundh  4 , Mohammed Altigani Abdalla  5   6 , Rami H Al-Rifai  7
Affiliations
Meta-Analysis

Associations between maternal overweight and obesity with cesarean section delivery in Middle East and North Africa region: a systematic review, meta-analysis, and attributable risk

Basem Al-Omari et al. Syst Rev. .

Abstract

Background: Over the past 30 years, the global use of cesarean section (CS) has increased significantly, surpassing the recommended population-based rate of 10-15%. Increased maternal weight is a major factor for cesarean section (CS) delivery.

Objective: This systematic review and meta-analysis assessed the association between maternal overweight/obesity and CS delivery, estimating the proportion of CS deliveries attributable to excess maternal weight in Middle East and North Africa (MENA) countries.

Methods: Electronic databases (PubMed, Scopus, Embase, CINAHL, Web of Science, and Cochrane) were searched for studies published between Jan 2000 and Nov 2024 in MENA countries. Two authors reviewed studies and extracted data. Subgroup analyses examined obesity class (I-III) and CS type. Attributable risk fractions (ARFs) and population-attributable risk fractions (PARFs) were calculated. Random-effects models were used.

Results: Forty-five studies from 12 MENA countries, including 97,518 women, were analyzed. Compared to women with a normal body mass index (BMI), overweight and obese women had a 35.0% (aOR 1.35; 95% CI, 1.24-1.49) and a 77.0% (aOR 1.77; 95% CI, 1.49-2.11) elevated likelihood of CS, respectively. The likelihood of CS significantly increased with increasing obesity class by 78% for class I, 121% for class II, and 161% for class III. Overweight women were also at higher risk of emergency CS (aOR 1.34; 95% CI, 1.02-1.76). An estimated 25.9% and 43.5% of CS deliveries were attributable to maternal overweight and obesity. The highest estimated PARF for maternal overweight was in Syria (15.9%) and for obesity in Saudi Arabia (35.4%).

Limitations: Few included studies lacked standardized definitions or classifications of BMI and maternal weight, which may have affected comparability. Substantial heterogeneity was observed in subgroup analyses, requiring cautious interpretation of the pooled estimates.

Conclusions: Promoting healthy weight before and during pregnancy could reduce unnecessary and emergency CS deliveries, offering a critical intervention for improving maternal health.

Systematic review registration: PROSPERO CRD42024551878.

Keywords: BMI; Cesarean section; MENA; Maternal weight.

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Conflict of interest statement

Declarations. Ethics approval and consent to participate: Not applicable. This manuscript does not contain any data involving individual human participants in any form. The review is based solely on previously published data from peer-reviewed journals. As such, ethical approval and informed consent were not required. Competing interests: Nothing declared.

Figures

Fig. 1
Fig. 1
PRISMA flow chart for selecting studies on maternal weight and cesarean section
Fig. 2
Fig. 2
Geographical distribution of the 45 studies reported from 12 countries in the MENA region and included in the systematic review
Fig. 3
Fig. 3
Forest plot depicting crude odds ratio estimating the strength of association between overweight and obesity with C-section (crude odds ratio)
Fig. 4
Fig. 4
Forest plot depicting the adjusted odds ratio estimating strength of association between overweight and obesity with CS delivery
Fig. 5
Fig. 5
Forest plot depicting crude relative risk estimating strength of association between overweight and obesity with CS delivery
See this image and copyright information in PMC

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