<![CDATA[Cesarean section (CS) rates have increased substantially worldwide, with a growing proportion performed without clear medical indications, raising concerns about avoidable maternal and neonatal risks, healthcare costs, and health system inefficiencies. In Mataram City, Indonesia, hospital-based CS rates exceed 60%, substantially higher than national levels and international recommendations, yet evidence regarding the decision-making processes underlying this pattern remains limited. This study aimed to explore how clinical, sociocultural, and health system factors interact to shape CS decision-making in Mataram City. A qualitative case study was conducted from June to August 2025 using in-depth interviews with women who voluntarily chose CS without emergency indications, obstetricians, and nursing staff, as well as focus group discussions with midwives recruited purposively from public and private healthcare settings. Data were analyzed thematically using the Health Belief Model as an analytical framework. Five interrelated domains shaped CS decision-making: medical considerations, maternal and family perceptions, social interactions, healthcare provider authority, and childbirth financing mechanisms. Relative medical indications emerged as critical triggers that legitimized maternal preferences for CS by amplifying perceived risks within asymmetrical patient provider relationships. Overall, CS decision-making was shaped by the interaction of clinical assessments, sociocultural norms, provider authority, and health system financing. Strengthening shared decision-making, standardizing antenatal counseling, improving maternal health literacy, and addressing financial incentives may help reduce unnecessary CS while preserving maternal autonomy and ensuring maternal and neonatal safety. ]]>
