Factors Associated with Operationally Defined Caesarean Section Acceptance among Pregnant Women in Bosaso, Somalia: A Secondary Analysis

Background Caesarean section (CS) is a life-saving obstetric intervention, yet acceptance remains low in many low-resource settings. Evidence on CS acceptance among pregnant women in Bosaso, Puntland, Somalia, is limited. This secondary analysis assessed factors associated with an operationally defined CS acceptance outcome among pregnant women attending antenatal care at Bosaso General Hospital. Methods We analysed data collected between 1 January and 15 March 2026 from 384 pregnant women older than 18 years recruited through systematic random sampling. Verbal informed consent was obtained. Acceptance was derived from the item, “In certain medical situations, a C-section may be preferred over vaginal delivery”; Strongly Agree/Agree was classified as acceptance and Disagree/Strongly Disagree as non-acceptance. Nine knowledge items (Q7–Q15) were excluded because of identical within-respondent response patterns. Descriptive statistics and binary logistic regression were used; variables with bivariate p < 0.25 entered the multivariable model, with significance set at p < 0.05. Results Of 384 respondents, 108 (28.1%) were classified as accepting CS and 276 (71.9%) as not accepting CS. Socio-demographic and obstetric characteristics were not significantly associated with acceptance (all omnibus p > 0.25). Ten of 12 perception/barrier items were significant in bivariate analysis, including husbands’/relatives’ beliefs (COR = 1.61, 95% CI: 1.00–2.58, p = 0.0496). In the multivariable model, only agreement that CS has negative effects (AOR = 2.07, 95% CI: 1.24–3.46, p = 0.005) and that CS-related complications make acceptance difficult (AOR = 2.92, 95% CI: 1.74–4.91, p < 0.001) remained significant. Conclusion Operationally defined CS acceptance was low. The two significant adjusted associations were counter-intuitive and should not be interpreted causally because the study was cross-sectional and the outcome was a proxy derived from a general attitudinal item. Future studies should use a directly worded, validated acceptance measure.