Egypt’s Health Ministry is taking action to reduce the country’s high Caesarean section birth rate to protect the health of mothers and babies, while easing the financial burden on the government.
C-sections, whereby a baby is delivered through incisions in the mother’s abdomen and uterus, accounted for 72 per cent of births in Egypt in 2021, data by the country’s statistics agency released last month showed.
That is more than three times the global average of about 20 per cent and among the world’s highest C-section rates.
The World Health Organisation says Egypt is one of only five countries where C-sections outnumber natural deliveries — the others being Dominican Republic, Brazil, Cyprus and Turkey.
Earlier this month, Minister of Health and Population Khaled Abdel Ghaffar ordered new measures to lower the rate of “unjustified” C-sections. He said that the vast majority showed no medical need for the procedure.
The measures include offering financial incentives to mothers who choose natural birth; educating citizens about the dangers and long-term effects of C-sections; making doctors charge equal fees for natural and Caesarean births to prevent performing the C-sections for financial gain; training nurses and midwives to support doctors; and introducing legislation to protect doctors in cases of minor side effects while performing natural births.
C-section rates have been increasing steadily in Egypt, from less than 5 per cent in 1992 to about 10 per cent in 2000 and 52 per cent in 2014, national surveys found.
Worldwide Caesarean section rates have also risen, but at a far slower rate — from 7 per cent in 1990 to 21 per cent last year. The number is set to continue increasing, with nearly a third of all births likely to take place by Caesarean section by 2030, a WHO study found.
The WHO says a C-section rate of 10 to 15 per cent is optimal. Anything higher creates an excessive burden on resources needed for the care of the mother and child and exposes them to health risks.
The surgery can be a lifesaving procedure, but can also lead to infection, haemorrhage and blood clots, slower recovery from childbirth and increased likelihood of complications in future pregnancies.
Overuse of Caesarean sections was estimated to have cost the Egyptian healthcare system more than 900 million pounds ($46m) in 2014, non-profit research group the Population Council said. The staff time, medicines, supplies and equipment associated with an average vaginal delivery cost the state 664 pounds, while a C-section delivery cost an average of 1,076 pounds.
Why is Egypt’s C-section rate so high?
Dr Bismeen Jadoon, a UK-based consultant obstetrician and gynaecologist, has conducted research with the WHO and the Egyptian Committee of Royal College of Obstetricians and Gynaecologists that gives insight into why the rate is particularly high in Egypt.
It is not as straightforward as one might think, she tells The National. In a 2019 study, the WHO looked at the determinants of Caesarean birth rates in the Eastern Mediterranean region, which covers 22 states spanning from Morocco to Pakistan.
While Egypt, Iran and Lebanon had exceptionally high Caesarean birth rates of 52 per cent, 48 per cent and 46 per cent, respectively, Somalia and Afghanistan had extremely low rates of less than 5 per cent.
Pre-disposing factors included a woman’s age, her education, how many children she has had already, whether she lived in an urban or rural setting, and cultural beliefs.
Women above age 35 with a higher education status are more likely to go for a Caesarean birth and often at their own request, Dr Jadoon says.
In Egypt, women with secondary education had a Caesarean birth rate of 58 per cent, while women with no education had a 37 per cent C-section rate. Sixty per cent of urban births were Caesarean, compared with 48 per cent in rural areas.
In general, mothers with more than three children were likely to have Caesarean births. However, in Egypt, women with two children or less were twice as likely to undergo Caesarean birth than women with a higher number of children.
Cultural norms and values also play a role. One of the reasons why women in many African countries are reluctant to go through a C-section is that the society considers surgery “a form of slaughter”, Dr Jadoon says.
In contrast, in Middle Eastern countries, “some women are saying it’s actually their husbands who are requesting the Caesarean section because they don’t want their sexual life to be affected”, she says.
The reality is that “a woman’s pelvis is mostly affected during the nine months when she’s pregnant, rather than the few hours of labour”, says Dr Jadoon, underscoring the importance of effective labour management and post-delivery pelvic floor exercises.
Enabling factors included socioeconomic status and access to healthcare centres.
Two thirds of births among Egyptian women in the highest wealth quintile were Caesarean deliveries, compared with 38 per cent among women in the lowest wealth quintile, a 2014 national health survey found.
Medical factors determining the need for C-sections included previous Caesarean births, foetal malpresentation, failure to progress in labour, foetal distress, twins and pre-term deliveries.
How many of Egypt’s C-sections are unjustified?
To understand what percentage of Egypt’s Caesarean sections are unjustified, Dr Jadoon and other researchers conducted a study at eight hospitals over a three-month period in 2018.
They used the Robson system, which classifies women who undergo childbirth in 10 groups, according to such factors as the category of the pregnancy, the woman’s previous obstetric record, the labour course and the gestational age at delivery.
Of 8,080 women in the study, 5,006 delivered by Caesarean. Most of this group, 57 per cent, had had previous deliveries by C-section. Meanwhile, 14 per cent were delivering pre-term and 8 per cent had normal pregnancies but needed induced labour that was unsuccessful, ultimately requiring a C-section.
“What we have proven is that you need to prevent the first unnecessary Caesarean section," Dr Jadoon says. "Because what’s happening in Egypt is once you have a Caesarean section, it’s always a Caesarean section the next time around."
While it is safe to try for a normal delivery after previous C-sections, it requires a special protocol and close monitoring of the mother and baby. This is often not possible in developing countries where resources are limited, Dr Jadoon says.
Is the patient or the doctor to blame?
Dr May Hobrok, an Egyptian obstetrician and gynaecologist who has been in practice for more than 30 years, says there is both a patient and doctor factor in the high incidence of unnecessary Caesareans.
Young women requesting the procedure “are very well-educated, but they don’t have health awareness”, Dr Hobrok says. “You try to convince them from a scientific point of view and they are still asking for a C-section.”
Some doctors do the procedure out of time convenience, financial gain or fear of litigation. Since there is no midwifery system in Egypt, where 2.2 million babies are born annually, doctors are overburdened by normal deliveries.
Although Dr Hobrok and others say that money is not the main driver, the Population Council estimated a Caesarean at a private centre costs between 2,000 and 5,000 pounds. This is compared with 1,000 to 2,000 pounds for a vaginal delivery.
Dr Amr El Noury, honorary chairman of the Egyptian Committee of Royal College of Obstetricians and Gynaecologists, is part of a coalition formed in 2019 to reduce unnecessary C-sections.
He says women need to be educated about the labour process through antenatal classes and awareness campaigns, as many are scared of the pain.
“They listen to the horror stories of delivery … even movies in the Middle East usually show someone in labour who is really in severe pain or is going to die,” says Dr El Noury, a professor of obstetrics and gynaecology at Cairo University.
Doctors need to be trained in the use of instruments, such as forceps or suction cups, for assisted vaginal deliveries, rather than automatically resorting to surgery, he says.
He also recommends setting up a midwife or doula system, such as in the UK.
The Covid-19 pandemic sidetracked the coalition’s goals. But now the health ministry has responded to these recommendations positively, as is evident by the recent directives.
“I hope in the coming period we can put a stop to the vicious cycle of C-sections and at least women can have an opportunity to have a normal labour,” Dr El Noury says.