Prevalence and risk factors of preoperative anxiety in women undergoing cesarean section: A global systematic review and meta-analysis.

INTRODUCTION: Preoperative anxiety is a significant psychological concern among women undergoing cesarean delivery, with potential implications for maternal and neonatal outcomes. This systematic review and meta-analysis aimed to (1) quantify the global prevalence of preoperative anxiety in women undergoing cesarean sections, (2) identify key risk factors, and (3) assess geographical variations in anxiety patterns. MATERIALS AND METHODS: Following PRISMA guidelines, we systematically searched PubMed, Scopus, Web of Science, and Cochrane Library without time restrictions, including studies published in English or Persian, up to April 2025. Observational studies reporting prevalence and/or risk factors of preoperative anxiety in women (≥18 years) undergoing cesarean delivery were included. Study quality was assessed using a modified version of the Newcastle-Ottawa Scale, and heterogeneity was evaluated via the I2 and Q statistic. Random-effects meta-analyses with Freeman-Tukey transformation were conducted for pooled prevalence estimates, with subgroup analyses by geography, income level, and assessment tools. Meta-regression explored temporal trends and moderators. RESULTS: Of 950 identified records, 24 studies (n = 3928) were included. The pooled prevalence of preoperative anxiety was 66.7% (95% CI: 58.3-74.5%), with high heterogeneity (I2 = 96.7%). Prevalence varied significantly by country (25.0% in Malaysia to 98.0% in Turkey), WHO region (p < 0.001), and income level (70.8% in upper-middle-income vs. 41.0% in high-income countries; p < 0.001). Risk factors included higher education (OR = 1.67, 95% CI: 1.25-2.22) and primiparity (OR = 1.62, 95% CI: 1.03-2.57). No difference was observed between elective and emergency cesarean deliveries (p = 0.670). Meta-regression revealed a temporal decline in prevalence (β = -0.068 per year, p = 0.003). CONCLUSION: This meta-analysis suggests that nearly two-thirds of women experience preoperative anxiety before cesarean delivery, with higher burden in upper-middle-income countries and among educated or first-time mothers. The lack of difference by surgical urgency underscores the need for universal anxiety screening and tailored interventions. Geographical disparities and declining temporal trends highlight the importance of context-specific strategies and further research into underlying mechanisms.