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Epidemiology of surgical site infections post-cesarean section in Africa: a comprehensive systematic review and meta-analysis

BMC Pregnancy and Childbirth volume 25, Article number: 465 (2025) Cite this article

Abstract

Background

Surgical site infections (SSIs) are among the most common postoperative complications following cesarean section, particularly in Africa. These infections pose maternal health risks, including prolonged hospitalization, increased healthcare costs, and mortality. This systematic review and meta-analysis aimed to evaluate the epidemiology, pooled prevalence, and risk factors for SSIs after cesarean section in Africa.

Methods

A systematic search of PubMed/MEDLINE, Scopus, and Web of Science databases was conducted to identify studies published between January 2000 and December 2023. The review followed PRISMA 2020 guidelines, and 41 studies spanning 18 African countries met the inclusion criteria. Data on SSI prevalence and risk factors were extracted, and the quality of studies was assessed using the Newcastle–Ottawa Scale. A random-effects model was used to estimate pooled prevalence, with subgroup analysis, sensitivity analyses, and meta-regression exploring variations across study characteristics. Publication bias was assessed using funnel plots.

Results

The pooled prevalence of SSIs after cesarean section was 11% (95% CI: 9–12.9%) with substantial heterogeneity (I2 = 97%, < 0.001). Regional variations were observed, with the highest prevalence in Tanzania (34.1%) and Uganda (15%), and the lowest in Tunisia (5%) and Egypt (5.3%). Temporal trends revealed a peak in prevalence (16%) during 2011–2015, declining to 9.8% by 2016–2020. Prolonged rupture of membranes (PROM) was the most frequently reported risk factor (OR: 4.45–13.9), followed by prolonged labor (> 24 h) (OR: 3.48–16.17) and chorioamnionitis (OR: 4.37–9.74). Potential publication bias indicated by asymmetrical funnel plots.

Conclusion

SSIs following cesarean section remain a burden in Africa, with wide regional variations and multiple preventable risk factors. The findings highlight the need for targeted interventions, including improved infection control practices, antenatal care, and timely management of obstetric complications.

Peer Review reports

Introduction

Cesarean section (CS) is a critical component of modern obstetric care, playing a vital role in reducing maternal and neonatal mortality in complicated deliveries [1]. In the past three decades, worldwide cesarean section rates have increased due to transformations in healthcare, evolving maternal demographics, and alterations in clinical procedures [2]. Cesarean deliveries account for approximately 10%–15% of births in specific contexts, a range that has been associated with improved maternal and neonatal health outcomes. Nevertheless, the World Health Organization (WHO) underscores the importance of ensuring that cesarean sections are performed only when medically justified, highlighting the need for appropriate clinical indications to optimize both maternal and neonatal health while avoiding unnecessary interventions. In many regions, including parts of Africa, Asia, and developed countries, cesarean section rates are high, often without corresponding improvements in health outcomes [3]. For example, around one-third of babies in Australia and the United Kingdom are delivered by cesarean section, with rates exceeding 40% in nations like China [2, 4, 5]. In Africa, a study from Egypt demonstrated a marked exponential increase in cesarean deliveries over time, with population-based data indicating a surge from 17.8% in 2000 to 59.7% in 2014 [6].

The burden of associated complications increases as the incidence of cesarean sections increases. Surgical site infections (SSIs) are notably alarming, being one of the most prevalent postoperative consequences after a cesarean delivery with a reported prevalence of 3%–20% [7]. SSIs include infections associated with superficial or deep wounds, as well as organ-space infections, often manifesting within 30 days after surgery [8]. These infections provide hazards to maternal health, resulting in extended hospitalizations, elevated healthcare expenses, and, in some instances, fatal consequences [9]. Women having cesarean sections have a five to 20-fold increased risk of acquiring surgical site infections compared to those delivering vaginally, highlighting the need for focused preventive and control strategies [10, 11].

In Africa, SSIs following cesarean sections represent a maternal health challenge. The number of infections is elevated compared to high-income settings and indicates systemic issues, including restricted access to infection control services, inconsistent surgical techniques, and insufficient follow-up care [12]. The discrepancy is further intensified by patient-related variables like obesity, anemia, and diabetes, along with procedural factors such as emergency procedures and extended operating durations. Insufficient administration of prophylactic antibiotics and extended rupture of membranes have been recognized as major factors [13].

Despite the burden of SSIs, they can be prevented through evidence-based interventions [9]. However, in many low- and middle-income regions, particularly in Africa, inconsistent implementation of evidence-based interventions and the lack of established surveillance systems hinder progress [14]. Furthermore, discrepancies in SSI definitions and follow-up procedures hinder the comparison of prevalence rates and the establishment of standardized recommendations [14].

This systematic review and meta-analysis aims to fill these gaps by providing a thorough evaluation of the epidemiology of surgical site infections after cesarean sections in Africa. This study assesses the pooled prevalence of SSIs and identifies risk factors by synthesizing existing data. The findings will guide evidence-based policy, enhance infection prevention and control measures, and ultimately enhance maternal health outcomes across the continent.

Methods

Study design

This systematic review and meta-analysis aimed to evaluate the prevalence of SSI following cesarean sections across African countries. The study was guided by the PICO framework:

  • Population (P): Women undergoing cesarean sections in African countries.

  • Intervention/Exposure (I): Cesarean section as the surgical procedure.

  • Comparison (C): Not applicable, as this is a prevalence study.

  • Outcome (O): Prevalence of surgical site infections following cesarean sections.

The study adhered to the guidelines outlined in the Cochrane Handbook for Systematic Reviews of Interventions and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement [15, 16].

Search strategy

A literature search was conducted across three major electronic databases: PubMed/MEDLINE, Scopus, and the Web of Science. The search was performed in December 2023 and targeted studies published between January 2000 and December 2023. Search terms included a combination of Medical Subject Headings (MeSH) terms and free-text keywords such as"Surgical Site Infections,""Cesarean Section,"and"Prevalence."To ensure a comprehensive search, the names of all 54 African countries were explicitly included as part of the search terms (e.g.,"Nigeria,""Ethiopia,""Tanzania,""Egypt,"etc.), either individually or in conjunction with broader terms like"Africa"or"sub-Saharan Africa."Boolean operators (AND, OR) were used to combine terms and refine the search results (Additional file 1). Additionally, filters for publication year and language (English only) were applied. The reference lists of all included articles were manually screened to identify any additional relevant studies that may have been missed during the database search.

Inclusion criteria

Studies were included if they met the following criteria: they reported data on the prevalence or incidence of SSI specifically following cesarean sections; were conducted in African countries and identified the country of origin; were published between January 2000 and December 2023 in the English language; utilized prospective or retrospective cohort designs, cross-sectional studies, or randomized controlled trials (RCTs) and presented original data; and provided sufficient numerical data, including the number of participants screened and the number of SSI cases identified, to allow for prevalence calculation. Additionally, studies were required to define SSI according to standardized criteria, such as the CDC criteria for superficial, deep, or organ/space infections.

Exclusion criteria

Studies were excluded if they met any of the following criteria: they were conducted outside African countries or included mixed African and non-African populations without separately reported data; were case reports, review articles, editorials, commentaries, or conference abstracts without original data; focused on populations other than women undergoing cesarean sections, such as general surgical or mixed obstetric populations; were published in languages other than English; lacked sufficient data to calculate prevalence rates; or were duplicate publications or reported overlapping datasets without unique data.

Study selection

The process of study selection was systematic and structured. All retrieved articles were imported into Rayyan (https://www.rayyan.ai/), a web-based platform for systematic reviews, where duplicates were automatically identified and removed [17]. Ten independent reviewers screened the titles and abstracts of all articles to exclude studies that were irrelevant or did not meet the eligibility criteria. Any disagreements were resolved through discussion or consultation between them. Articles deemed eligible or potentially eligible were then subjected to a full-text review by four reviewers. The inclusion of studies was finalized by consensus, ensuring that all selected studies adhered strictly to the predefined criteria.

Data collection and extraction

Data were independently extracted by four reviewers using a standardized data extraction form. To ensure accuracy, another four reviewers performed a re-extraction of the data. Extracted data included study characteristics (e.g., authors, year of publication, and study design), country, number of participants screened, number of SSI cases, and prevalence rates. Other extracted variables included methodological details, risk factors, and outcomes, where available. Since income levels and Human Development Index (HDI) scores were not reported in any of the included studies, these data were independently obtained from the United Nations Development Programme databases to provide additional context for analysis [18]. Countries were subsequently stratified according to World Bank income categories, gross national income (GNI) per capita, and HDI levels [18, 19]. The data extraction form was pretested to ensure completeness and consistency. Any discrepancies between reviewers were resolved through discussion and consultation with two additional reviewers to ensure accuracy and reliability.

Quality assessment

The quality of included studies was assessed using the Newcastle–Ottawa Scale (NOS), a widely used tool for evaluating non-randomized studies [20]. Each study was evaluated in three domains: selection of participants, comparability of study groups, and ascertainment of outcomes. Based on these criteria, a score was assigned to each study, with scores ranging from 0 to 9. Studies were categorized as high quality (scores of 7–9), moderate quality (scores of 4–6), or low quality (scores of 0–3). Four independent reviewers scored each study. To resolve cases of discordance, disagreements in quality assessments were first discussed among the four reviewers. If consensus could not be reached, two additional reviewers were consulted to make a final decision, ensuring uniformity and accuracy in the evaluation process (Additional file 2).

Statistical analysis

Statistical analyses were performed using MetaXL version 5.3 with a random-effects model to estimate pooled prevalence rates of SSI, accounting for heterogeneity [21]. Prevalence estimates were reported with 95% confidence intervals (CIs). Heterogeneity was assessed using Higgins’ I2 statistic, with Cochran’s Q test quantifying variability. Forest plots were generated to display individual and pooled prevalence estimates, while publication bias was evaluated using funnel plots. A random-effects model was chosen for the meta-analysis due to the high heterogeneity observed across studies. This model accounts for variability between studies by assuming that the true effect size may differ across populations and settings, providing a more conservative and generalizable estimate of SSI prevalence. Sensitivity analyses systematically excluded individual studies to assess the robustness of pooled estimates. Spatial and temporal trends in SSI prevalence were analyzed using Python. Geospatial maps depicting country-specific prevalence were created with matplotlib, geopandas, and shapefile, highlighting regional disparities. Temporal trends were examined by stratifying studies into five-year intervals and plotting average prevalence rates with matplotlib. A meta-regression analysis was performed to investigate potential sources of heterogeneity and assess the influence of study-level covariates on the prevalence of SSIs. The meta-regression was conducted using a random-effects model, with the restricted maximum likelihood (REML) method for estimating between-study variance.

Results

Article screening and selection

A total of 1,187 records were identified through database searches (PubMed: 438, Scopus: 487, and Web of Science: 262), as shown in Fig. 1. After the removal of 380 duplicates, 807 articles remained for screening. A further 728 records were excluded due to being off-topic (477 studies), non-African studies (161), reviews (61), or protocols/editorials (29). A total of 79 articles underwent full-text evaluation, of which 38 were excluded due to the absence of data on the outcome of interest. Ultimately, 41 studies met the eligibility criteria and were included in the qualitative and quantitative synthesis (Find the references for them in Additional file 3).

Fig. 1
figure 1

Flow diagram of articles screening and selection process for studies

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Characteristics of the included studies

A total of 41 studies were included in this systematic review, spanning 18 African countries (Table 1). Study designs varied, with a mix of prospective (n = 13), retrospective (n = 10), cross-sectional (n = 13), and randomized controlled trials (RCTs, n = 5). Sample sizes ranged from 136 participants (Ernest et al., 2021) to 15,502 participants [7, 22]. The included studies reported SSI prevalence rates between 3.5% (Akimana et al., 2021, Rwanda) and 48.2% (De Nardo et al., 2016, Tanzania) [23, 24]. The majority of studies (n = 25) were conducted in lower-middle-income settings, while the rest (n = 16) were from low-income countries [18, 19]. Quality assessment using the Newcastle–Ottawa Scale (NOS) revealed that 14 studies were rated as high quality, 25 as moderate quality, and 2 as low quality. A detailed assessment of the quality of the included studies is presented in Additional File 2.

Table 1 Study characteristics and demographics of Surgical Site Infection (SSI) investigations in post-cesarean section cases
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Pooled estimates of surgical site infection rates

The pooled prevalence of SSIs in post-cesarean section patients across African countries was estimated at 11% (95% CI: 9–12.9%) using a random-effects model (Fig. 2). The high heterogeneity observed (I2 = 97%, p < 0.001) reflects substantial variability across studies, likely due to differences in study design, population characteristics, healthcare settings, and SSI definitions. While this heterogeneity limits the generalizability of the pooled prevalence estimate, the use of a random-effects model accounts for this variability, providing a more conservative and realistic summary estimate. Spatial analysis (Fig. 3) highlighted regional variation, with the highest prevalence observed in Tanzania (34.1%) and Uganda (15%), while lower rates were reported in Tunisia (5%) and Egypt (5.3%).

Fig. 2
figure 2

Forest plot of the prevalence of Surgical Site Infections (SSI) among post-cesarean section patients

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Fig. 3
figure 3

Map of SSI prevalence rates across African countries

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Temporal trends in SSI prevalence

Temporal trends in SSI prevalence, as shown in Fig. 4, indicate variations over the studied periods. From 2001 to 2005, the prevalence was relatively stable at around 10%. However, a notable increase was observed during 2011–2015, with an average prevalence rate peaking at 16%. By 2016–2020, a decline in prevalence to approximately 9.8% was observed.

Fig. 4
figure 4

Temporal trends in SSI rates across African regions (2001–2020)

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Subgroup analysis

Subgroup analysis revealed variations in SSI prevalence based on publication year, study design, sample size, and geographic region (Table 2). The prevalence of SSIs was highest during 2016–2020 (13.7%, 95% CI: 9.4–18.5%), compared to 7.8% (95% CI: 4.4–12.1%) during 2000–2009. Studies with smaller sample sizes (< 500 participants) reported a higher prevalence (12.6%) compared to larger studies (10.2%). Based on the study design, randomized controlled trials (RCTs) reported the highest prevalence (21.2%, 95% CI: 10.5–34.3%), while retrospective studies reported the lowest prevalence (8.9%, 95% CI: 6.9–11.2%). Cross-sectional and prospective studies showed intermediate prevalence rates of 9.8% (95% CI: 8–11.7%) and 11.6% (95% CI: 6.8–17.3%), respectively. When RCTs were excluded, the pooled prevalence across all other study designs was 10.3% (95% CI: 8–12%), indicating that the high prevalence observed in RCTs did not significantly skew the overall results. Additionally, regional subgroup analysis revealed significant disparities in SSI prevalence: West Africa had a prevalence of 10.2% (95% CI: 8.2–12.1%), East and Central Africa had a prevalence of 12.1% (95% CI: 9.2–15.3%), and North Africa had the lowest prevalence at 7.2% (95% CI: 4.1–13.3%).

Table 2 Subgroup analysis of surgical site infection (SSI) prevalence by publication year, study design, sample size, and geographic region
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Risk factors for surgical site infections

The studies reported various risk factors contributing to SSIs in post-cesarean section patients (Table 3). The identification and selection of risk factors were based on their consistent reporting across multiple studies and their statistical significance (e.g., p < 0.05) in univariate or multivariate analyses. Prolonged rupture of membranes (PROM) was the most frequently reported risk factor for SSIs across the included studies, with odds ratios (ORs) ranging from 4.45 (Ezechi et al., 2009) to 13.9 (Azeze et al., 2019) [27, 38]. This was followed by prolonged labor (> 24 h), with reported ORs ranging from 3.48 (Gelaw et al., 2017) to 16.17 (Wendmagegn et al., 2018) [33, 36]. Chorioamnionitis was the third most commonly reported factor, with ORs ranging from 4.37 (Molla et al., 2019) to 9.74 (Mamo et al., 2017) [34, 37]. Other significant risk factors included high body mass index (BMI > 25), with ORs ranging from 2.34 (Ezechi et al., 2009) to 5.98 (Nkurunziza et al., 2019), and severe anemia, with ORs ranging from 3.51 (Isanga et al., 2020) to 6.4 (Mamo et al., 2017) [27, 34, 48, 58]. Additional factors consistently associated with higher SSI risk were vertical skin incisions, emergency cesarean sections, and lack of preoperative antibiotics.

Table 3 Risk factors for Surgical Site Infections (SSI) in cesarean section patients, as reported in the included studies
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Publication bias and sensitivity analyses

The funnel plot analysis (Fig. 5) revealed potential publication bias, indicated by the asymmetrical distribution of study points around the pooled prevalence estimate. This may stem from underreporting of studies with low SSI prevalence or methodological inconsistencies across studies. To address this, sensitivity analyses were performed by systematically excluding individual studies to assess the robustness of the pooled prevalence estimate. The results, summarized in Additional File 4, confirm that the pooled prevalence remained consistent across exclusions, demonstrating the stability of the findings despite potential bias.

Fig. 5
figure 5

Funnel plot of SSI rates in post-cesarean section patients

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Meta-regression analysis

The meta-regression analysis was conducted to explore the influence of study-level moderators on the heterogeneity of prevalence estimates (Additional file 5). The included moderators were year of publication, study design (prospective, randomized controlled trials [RCT], and retrospective), geographic region, and sample size. None of the moderators demonstrated statistically significant associations with prevalence estimates (all p > 0.05). Notably, study design and geographic region showed negligible to modest effects, but these did not reach statistical significance. The model explained approximately 32.3% of the observed heterogeneity leaving a substantial proportion unaccounted for.

Discussion

This systematic review and meta-analysis provide a comprehensive assessment of the prevalence, regional distribution, and key risk factors associated with SSIs following cesarean section in Africa. The pooled prevalence of 11% highlights that SSIs remain a major maternal health issue in the region.

The pooled prevalence of 11%, is markedly higher than the prevalence reported in other regions, such as South-East Asia (7.04%) and North America (3.87%), as identified in a previous systematic review [60]. This disparity underscores critical differences in healthcare infrastructure, resource allocation, and infection prevention practices between Africa and regions with higher income levels and better HDI scores [60]. The elevated SSI rates in Africa are associated not only with individual patient risk factors but also with broader systemic challenges. Variations in SSI rates within the same healthcare settings suggest that other factors, such as staffing levels and adherence to guidelines, may also contribute to these disparities [61].

The study identified geographical variation in SSI prevalence across Africa, with higher rates observed in East and Central Africa (12.1%) compared to West Africa (10.2%) and North Africa (7.2%). Pronounced regional differences were evident, with the highest rates reported in Tanzania (34.1%) and Uganda (15%) and the lowest in Tunisia (5%) and Egypt (5.3%). These variations highlight the influence of disparities in healthcare infrastructure, economic resources, and the implementation of infection prevention strategies across different regions.

In regions with limited resources, such as Tanzania and Uganda, challenges include inadequate access to sterile surgical environments, shortages of essential supplies, and a lack of trained healthcare professionals [22, 24]. Additionally, gaps in infection monitoring systems and inconsistent perioperative care practices exacerbate the risk of infections [22]. For example, in Uganda, an SSI rate of 7.9% was linked to disparities in postoperative care, including hospital stays, antibiotic use, and wound dressing techniques such as closed-incision negative pressure wound therapy (ciNPWT) [62]. Similarly, in Ethiopia, prolonged operation duration increased the risk of SSI due to extended tissue exposure to bacterial contamination [63]. In rural Rwanda, challenges such as high transportation costs to healthcare centers and reliance on a single disinfectant solution for skin preparation contributed to elevated SSI risks [48].

In contrast, Tunisia and Egypt, which are classified as upper-middle-income countries with higher HDI scores, benefit from more developed healthcare systems. These nations are more likely to follow international standards for cesarean section care, including routine administration of prophylactic antibiotics, adherence to standardized surgical protocols, and implementation of robust infection control measures [7, 59]. Such practices contribute to their comparatively lower SSI rates, highlighting the critical role of systemic investments in improving maternal health outcomes.

Lower-income nations often operate under severely constrained healthcare budgets, which limit their ability to procure essential surgical supplies, maintain sterile environments, and invest in adequate healthcare infrastructure [64,65,66]. These systemic challenges are worsened by inadequate water, sanitation, and hygiene (WASH) facilities in many healthcare settings, which are essential for effective infection prevention and control [67]. Additionally, financial barriers, geographical distances, and cultural perceptions of formal healthcare services can delay care-seeking, increasing the likelihood of cesarean deliveries occurring in suboptimal conditions [68].

A temporal analysis of SSI prevalence revealed a notable peak of 16% during the 2011–2015 period, followed by a decline to 9.8% between 2016 and 2020. This trend aligns with the implementation of global maternal health initiatives, such as the Millennium Development Goals (MDGs) and their successor, the Sustainable Development Goals (SDGs) [69, 70]. These initiatives drove investments in maternal healthcare, including enhanced infection prevention practices, improved obstetric care, and strengthened surgical training. The decline in SSI prevalence post- 2015 can be attributed to several factors, including increased international donor funding and partnerships, which improved access to essential medical supplies and bolstered the healthcare workforce. Furthermore, global efforts, such as the World Health Organization’s (WHO) guidelines on antibiotic prophylaxis for cesarean sections, emphasized the adoption of evidence-based practices to reduce surgical site infections and improve maternal outcomes [71]. The WHO’s surgical safety checklist and infection prevention and control (IPC) guidelines have been promoted as tools to standardize surgical practices and mitigate infection risks. However, their implementation remains inconsistent across African healthcare settings, with studies reporting low adoption rates in some regions [72, 73]. These initiatives collectively strengthened healthcare systems, promoted adherence to best practices, and contributed to the observed reduction in SSI prevalence across many regions in Africa. Such progress underscores the importance of sustained investments in healthcare infrastructure and evidence-based practices to continue improving surgical outcomes.

This study identified several preventable risk factors for SSIs following cesarean sections, underscoring the need for targeted interventions to address these challenges. Among the most significant factors was prolonged rupture of membranes (PROM), with odds ratios ranging from 4.45 to 13.9. PROM increases the likelihood of ascending infections by exposing the sterile uterine environment to vaginal flora [74]. Strategies such as timely cesarean delivery and vigilant intrapartum monitoring are critical in reducing the duration of PROM and minimizing the associated infection risk [75]. Prolonged labor and chorioamnionitis were also found to significantly elevate SSI risk. Prolonged labor increases exposure to non-sterile conditions, while chorioamnionitis disrupts the protective uterine environment, further predisposing patients to infections [76]. Evidence-based practices like active labor management and the early administration of antibiotics can play a vital role in mitigating these risks [77].

Additional contributors to SSIs included high body mass index (BMI), anemia, and the use of vertical skin incisions. Obesity impairs wound healing by reducing tissue vascularization, while anemia hampers tissue repair by limiting the delivery of oxygen and nutrients [78]. Vertical skin incisions, often necessary during emergency procedures, were linked to increased tissue trauma and extended surgical times, both of which elevate infection risks [79]. Addressing these factors through preoperative optimization, including nutritional supplementation, weight management, and comprehensive antenatal care, is essential for improving outcomes [80].

Implications of the study

The findings of this study have important implications for clinical practice, public health policy, and future research. The high pooled prevalence of SSIs following cesarean sections in Africa (11%) underscores the urgent need for targeted interventions to reduce infection rates and improve maternal health outcomes. Clinically, the identification of key risk factors, such as prolonged rupture of membranes, prolonged labor, and lack of preoperative antibiotics, highlights opportunities for preventive measures, including timely surgical interventions, adherence to infection control protocols, and standardized use of prophylactic antibiotics.

At the policy level, these findings call for increased investment in healthcare infrastructure, particularly in low-resource settings, to ensure access to sterile surgical environments, adequate staffing, and essential medical supplies. Additionally, the regional disparities in SSI prevalence emphasize the need for context-specific strategies tailored to the unique challenges faced by different African regions. For researchers, this study highlights gaps in the current evidence base, such as the limited data on antimicrobial resistance patterns and the impact of community-based interventions, which should be prioritized in future studies.

Limitations

This study has several limitations. First, the study was not registered in PROSPERO, which is important for transparency in systematic reviews. However, PROSPERO registration is currently unavailable for prevalence and incidence studies, which further limits our ability to register this review. Additionally, we adhere to PRISMA 2020 guidelines, and future studies should ensure PROSPERO registration to enhance transparency. Second, the inclusion of randomized controlled trials (RCTs) in a high-incidence setting may have introduced variability. However, a sensitivity analysis excluding RCTs showed a consistent pooled prevalence (10.3%), indicating minimal influence on the results. The heterogeneity introduced by RCTs remains a limitation. Third, the search strategy was limited to PubMed, Scopus, and Web of Science, and non-English studies were excluded. This may have introduced language bias and limited comprehensiveness. Future reviews should include additional databases (e.g., EMBASE, Cochrane Library) and non-English studies to reduce bias. Fourth, substantial heterogeneity (I2 = 97%) was observed, likely due to differences in study designs, populations, and SSI definitions. While the use of a random-effects model and subgroup analyses helps account for this variability, the high heterogeneity limits the generalizability of the pooled prevalence estimate. This underscores the need for cautious interpretation of the findings.

Fifth, reliance on published studies may have introduced publication bias, as studies with lower SSI prevalence or non-significant findings may be underrepresented. While sensitivity analyses confirmed the robustness of the results, publication bias remains a concern. Sixth, the quality of included studies varied, with some relying on retrospective designs prone to recall bias and underreporting. The lack of standardized follow-up periods further limits cross-study comparisons. Lastly, the absence of data on antimicrobial resistance, a critical factor in SSI management, highlights an important gap for future research. Addressing antimicrobial resistance patterns will be essential for developing effective interventions to reduce SSIs in Africa.

Conclusion

Our study underscores the substantial burden of SSIs following cesarean sections in Africa, with a pooled prevalence of 11%. Systemic challenges and modifiable risk factors shape this high rate. Geographic and temporal analyses revealed disparities in healthcare infrastructure and infection prevention practices across regions, highlighting the uneven progress in addressing these infections. While recent improvements have been observed, driven by global health initiatives and greater adherence to evidence-based protocols, challenges remain. Addressing these issues requires a multifaceted approach: strengthening healthcare systems, improving antenatal and perioperative care, and closing gaps in resource allocation, infection prevention, and management of antimicrobial resistance. These efforts are essential to reducing SSI rates and improving maternal health outcomes in Africa.

Data availability

The datasets used and/or analyzed during the current study are available from the corresponding author upon reasonable request.

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  1. Mohamed Baklola and Mohamed Terra contributed equally to this work.

Authors and Affiliations

  1. Faculty of Medicine, Mansoura University, Mansoura, Egypt

    Mohamed Baklola, Mohamed Terra, Kawthar Abdulaziz Jafail & Alaa Jaffar Mohammed

  2. Nursing Administration and Education Department, College of Nursing, Prince Sattam Bin Abdulaziz University, Al-Kharj, 11942, Saudi Arabia

    Mohamed Gamal Elsehrawy

  3. Faculty of Nursing, Port Said University, Port Said, Egypt

    Mohamed Gamal Elsehrawy

  4. Medical Intern, Faculty of Medicine, Tabuk University, Tabuk, Saudi Arabia

    Hatoun Alali & Norah Majed Albalawi

  5. Faculty of Medicine, King Faisal University, Al-Hofuf, Saudi Arabia

    Sereen Saleem Aljohani

  6. Faculty of Medicine, Imam Mohammad Ibn Saud Islamic University, Riyadh, Saudi Arabia

    Aseel Ali Alomireeni

  7. College of Medicine, King Khalid University, Abha, Saudi Arabia

    Razan Mubarak Alqahtani

  8. Faculty of Medicine, Sana’a University, Sana’a, Yemen

    Naji Al-Bawah

  9. Qatif Central Hospital, Al Qatif, 32654, Saudi Arabia

    Mayas Hafez

  10. Public Health and Community Medicine Department, Faculty of Medicine, Mansoura University, Mansoura, Egypt

    Ghada Elkhawaga

  11. Faculty of Medicine, Mansoura National University, Mansoura, Egypt

    Ghada Elkhawaga

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Contributions

M.B. and M.T. initiated the research, conceptualized, wrote the protocol, searched the articles, and conducted the statistical analysis for this manuscript. M.G.E., H.A., S.S.A., A.A.A., R.M.A., N.M.A., K.A.J., A.J.M., M.H., and N.A. participated in data extraction and screening. H.A., R.M.A., and N.M.A. contributed to the drafting of the manuscript. M.B., R.M.A., and N.M.A. reviewed and revised the manuscript draft. M.B., M.T., and G.E. provided critical feedback and helped finalize the manuscript. All authors read and approved the final draft of the manuscript.

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Baklola, M., Terra, M., Elsehrawy, M.G. et al. Epidemiology of surgical site infections post-cesarean section in Africa: a comprehensive systematic review and meta-analysis. BMC Pregnancy Childbirth 25, 465 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12884-025-07526-y

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BMC Pregnancy and Childbirth

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