**1. Introduction**

Worldwide, 830 women die every day due to pregnancy or childbirth-related complications, and almost all maternal deaths (99%) occur in developing countries [1]. In Africa and South Asia, it is the leading cause of death for women of reproductive age. Another 5.7 million suffer severe or long-lasting illnesses or disabilities caused by complications during pregnancy or childbirth every year globally [1, 2]. Half of the world's maternal, newborn, and child deaths occur in sub-Saharan countries. The maternal mortality ratio in developing countries is 240 per 100,000 births versus 16 per 100,000 in developed countries [1, 2]. The risk of a woman dying in sub-Saharan Africa as a result of pregnancy or childbirth is 1 in 39, as compared to 1 in 4,700 in industrialized countries. In sub-Saharan Africa, children under the age of five are 15 times more likely to die than in high-income countries [1]. However, an estimated 74% of maternal deaths could be averted if all women had access to emergency obstetric care [2, 3]. The consequences of maternal mortality have a ripple effect in families, communities and nations. Children without mothers are less likely to receive proper nutrition, health care and education. The implications for girls tend to be even greater, leading to a continued cycle of poverty and poor health. And every year, over \$15 billion in productivity is lost due to maternal and newborn death, placing a huge burden on developing nations [2].

Preventable maternal morbidity and mortality is associated with the absence of timely access to quality care, defined as too little, too late (TLTL) which refers to either inadequate access to services, resources, care that is unavailable until too late to help or a combination of these factors [4]. Caesarean section (CS) is the most common obstetric intervention designed to prevent or treat life-threatening pregnancy or childbirth-related complications [5]. When it is done on a timely basis CS provides an appropriate opportunity to prevent adverse obstetric outcomes, including maternal death, stillbirth and neonatal death [6–8]. According to World Health Organization (WHO), a maximum of 15% of births have a medical justification for a caesarean section, rates above this do not improve maternal and fetal outcomes and are considered inappropriate and unnecessary [9].

However, CS used inappropriately is an obstetric intervention described as too much, too soon (TMTS) which refers the over-medicalisation of normal pregnancy and birth. TMTS includes unnecessary use of non-evidence-based interventions, as well as use of interventions that can be lifesaving when used appropriately, but harmful when applied routinely or overused [4]. CS carries risks for both the mother and her child and therefore the reason for conducting the surgery must outweigh any potential adverse outcome [10]. Maternal deaths and perinatal deaths following caesareans sections are disproportionately high in lower and middle income countries (LMIC) [11]. The maternal mortality after caesarean birth in Africa is 50 times higher than that of high-income countries [10]. Mothers in Sub-Saharan countries are 37 times more likely to die than those from LMIC in European and Central Asia after caesarean section, and the risk is high in countries with low caesarean section rates. The rates of stillbirths and perinatal deaths in caesarean section births were 56.6 and 84.7 per 1000 CS procedures respectively [11]. Compared to vaginal birth CS has an eightfold higher mortality risk for the mother with increased risk of infection and bleeding, and similarly, CS is associated with a high risk of infant death, preterm birth, breathing difficulties and iatrogenic injury [9, 12–15]. Other complications believed to contribute to mortality were intraoperative hypotension (75%), operative hemorrhage (53%), ventilation difficulty (14%), regurgitation of stomach contents (13%), pre-eclampsia (8%), and difficult intubation (1%) [10]. Furthermore, CS is associated with post-surgical complications such as postpartum hemorrhage and deep vein thrombosis which are major contributors to maternal mortality worldwide. CS is also a profitable surgical procedure for physicians and hospitals, despite the high cost of caesarean birth resulting in significantly increased health expenditure for individuals and families [16, 17]. In comparison, vaginal birth is associated with fewer risks, fewer interventions such as anesthesia pose a lower potential for postpartum morbidity, involves a shorter hospital stay, is more affordable, and encourages earlier and better bonding between mother and infant [18]. The inappropriate use of CS is likely to contribute to the disease burden of poor obstetric outcome rather than improve it [10].
