Elnakib et al.

BMC Pregnancy and Childbirth (2019) 19:411

https://doi.org/10.1186/s12884-019-2558-2

RESEARCH ARTICLE Open Access

Medical and non-medical reasons for

cesarean section delivery in Egypt: a
hospital-based retrospective study
Shatha Elnakib1* , Nahla Abdel-Tawab2, Doaa Orbay2 and Nevine Hassanein3

Abstract
Background: Caesarean section (CS) is an important lifesaving intervention that can reduce maternal and newborn
morbidity and mortality. The dramatic increase in CS rates globally has prompted concerns that the procedure may
be overused or used for inappropriate indications. In Egypt, CS rates are alarmingly high, accounting for 52% of all
deliveries. This study sought to (1) explore indications and risk factors for CS in public hospitals in four governorates
in Egypt and (2) examine health care provider factors impacting the decision to perform a CS.
Methods: We reviewed medical records for all deliveries that took place during April 2016 in 13 public hospitals
situated in four governorates in Egypt (Cairo, Alexandria, Assiut and Behera), and extracted information pertaining
to medical indications and women’s obstetric characteristics. We also interviewed obstetricians in the study
hospitals to explore factors associated with the decision to perform CS.
Results: A total of 4357 deliveries took place in the study hospitals during that period. The most common medical
indications were previous CS (50%), an “other” category (13%), and fetal distress (9%). Multilevel analysis revealed
that several obstetric risk factors were associated with increased odds of CS mode of delivery – including previous
CS, older maternal age, and nulliparity – while factors such as partograph completion and oxytocin use were
associated with reduced odds of CS. Interviews with obstetricians highlighted non-medical factors implicated in the
high CS rates, including a convenience incentive, lack of supervision and training in public hospitals, as well as
absence of or lack of familiarity with clinical guidelines.
Conclusion: A combination of both medical and non-medical factors drives the increase in CS rates. Our analysis
however suggests that a substantial number of CS deliveries took place in the absence of strong medical
justification. Health care provider factors seem to be powerful factors influencing CS rates in the study hospitals.
Keywords: Egypt, Maternal health, Reproductive health, Caesarean section, Indications

Background 67.3%, which is more than double that of Jordan and Saudi
Caesarean section (CS) is an important lifesaving oper- Arabia, Egypt’s regional neighbors [3]. Currently, Egypt
ation for both mother and child, and its use has increased has the third highest rates of CS globally, following the
dramatically over the last decade [1]. Mirroring global Dominican Republic (56.4%) and Brazil (55.6%) [1].
trends, CS rates in Egypt have steadily increased, reaching According to the Statement on Caesarean Section
52% of all deliveries according to the most recent 2014 Rates released by the World Health Organization,
Egypt Demographic and Health Survey (EDHS) and repre- population-based CS rates greater than 10% are not opti-
senting more than a 100% increase in the CS rate since mal [4]. Although WHO has indicated that countries
2005 [2]. The proportion of institutional-based CS is should not strive to achieve a specific rate, the rationale
for the 10% recommendation is based on a systematic
review and ecological analysis which have shown that CS
* Correspondence: [email protected]
1
Department of International Health, Johns Hopkins Bloomberg School of
rates exceeding 10% are not correlated with reductions
Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA in maternal and newborn mortality [5, 6]. Instead high
Full list of author information is available at the end of the article

© The Author(s). 2019 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Elnakib et al. BMC Pregnancy and Childbirth (2019) 19:411 Page 2 of 11

CS rates may increase maternal risks, adversely impact increase in CS deliveries necessitates an institutional-
future pregnancies and overstretch health systems [7, 8]. based examination of the medical and non-medical
According to a 2010 report, the global cost of excess CS drivers of CS to allow for a deeper understanding of why
is US$ 2.32 billion [9]. the CS rate is increasing and what can be done to curb
Reasons behind the global increase in CS are multifa- this increase [3]. To understand medical indications and
ceted and include both clinical and non-clinical factors. health care provider factors associated with the high CS
Changes in risk profiles of women, a purported rise in rates, we conducted a retrospective review of medical
medical indications as well as non-medical reasons in- records of all deliveries that took place in 13 public hos-
cluding social, cultural and economic factors underlie pitals situated in four governorates in Egypt. The review
the increase in CS rates in many settings [10–13]. An- was triangulated with structured interviews with 275
other factor implicated in the increase in CS rates is the physicians in the study hospitals. The specific aims of
“physician factor,” which attributes the rise in CS not to the study were two-fold: [1] to explore documented indi-
obstetric risk factors, but to physician-related and insti- cations and risk factors for CS in a sample of public
tutional reasons [14–16]. hospitals and [2] to examine health care provider factors
In Egypt, significant progress has been achieved with that may be responsible for the increased CS rates, such
regards to maternal health and safe motherhood. The as financial and non-financial incentives, training, and
maternal mortality rate declined from 106 per 100,000 supervision.
live births in 1990 to 45 per 100,000 in 2013 [17].
According to EDHS 2014, coverage of antenatal care in- Methods
creased to 90% and facility delivery increased to 87% - a Study setting
marked improvement compared to EDHS 2008 in which A total of 13 public hospitals were selected in four gov-
71.6% of deliveries took place in a health facility [18, 19]. ernorates – one in Upper Egypt, one in Lower Egypt,
It is worth noting that the last round of EDHS revealed and two Urban Governorates. The study governorates
that most deliveries were assisted by doctors (88%) and were Assiut (n = 3 hospitals), Behera (n = 3 hospitals),
only 3% were assisted by nurse-midwives [19]. As such, Alexandria (n = 3 hospitals), and Cairo (n = 4 hospitals).
the role of nurse-midwives in delivery is limited. CS rates vary across the four governorates, ranging from
Hospital nurses typically have a very narrow scope of 35 to 68% according to the most recent 2014 EDHS data
work and their role in the delivery room is restricted to (See Fig. 1).
assisting the obstetrician. Nurse/midwives, on the other Medical records were abstracted for all deliveries that
hand, receive midwifery training and are certified to con- took place in the study hospitals during the month of
duct childbirth at home or at the primary health care April, 2016.
facility to which they are affiliated [20, 21]. Cases how- Both the study protocol and data collection instru-
ever are limited to those that are low-risk, while high- ments were reviewed and approved by the Population
risk cases are referred to the nearest hospital. Council’s Institutional Review Board and the Ethics
In 2016 – the year in which this study was carried out Committee of the Egyptian Ministry of Health and
– a total of 2,600,173 deliveries took place in Egypt, Population (MoHP). IRB approval was obtained on
most of which occurred in health facilities [22]. Concur- February 2nd, 2016 (protocol #722).
rent with the increase in facility-based deliveries, CS
rates have increased at an alarming rate [3]. The high Study sample
rate of CS delivery is concerning in light of the associ- Data collection in the 13 hospitals over the month of
ation of non-medically indicated CS with maternal and April 2016 yielded a total of 4357 medical deliveries.
fetal complications [23, 24] and suggests that caesarean Additionally, structured interviews with all obstetricians
delivery might be overused or used for inappropriate in- who were available during the data collection period and
dications. Key to ensuring that CS is being performed who worked in the Ob/Gyn ward of the study hospitals
for appropriate clinical reasons is routine monitoring – were conducted. A total of 275 physicians were inter-
and audits of medical record data from institutional viewed to identify physician and hospital factors related
deliveries. Population studies rarely provide accurate in- to the performance of CS in the study hospitals.
formation on indications for CS delivery nor on the ob-
stetric characteristics of women undergoing CS [25–27]. Data collection
Indeed, there is a general paucity of studies elucidating Data from medical records – which are paper-based in
physician-documented indications [28, 29] and in Egypt, Egypt – were collected using an abstraction form. Junior
this is coupled with a lack of data illustrating the obstet- residents were trained in the respective hospitals on
ric risk factors for CS delivery. The most recent study extracting data from hospital archives and filling the ab-
analyzing CS trends in Egypt noted that the exponential straction forms provided. They were instructed to get
Elnakib et al. BMC Pregnancy and Childbirth (2019) 19:411 Page 3 of 11

Fig. 1 C-section rates in Egypt by governorate according to EDHS 2014. We generated the map of Egypt using ArcMap 10.6 to depict the
distribution of CS rates by governorate

back to physicians and nurses if they encountered miss- listed in the patient file. ICD-10 codes for medical indi-
ing data. Population Council staff conducted regular cations were grouped into the following categories [8]: 1.
monitoring visits to ensure correct data extraction. Data Fetal distress/non-reassuring fetal status, 2. abnormal lie,
from medical records was recorded anonymously. The 3. amniotic fluid disorder including oligo and poly-
abstraction form included patient profile variables, his- hydramnios, 4. macrosomia, 5. multiple gestation, 6. pro-
tory of mode of delivery – specifically history of previous longed and obstructed labor including cervical dystocia,
CS, as well as maternal and fetal medical indications. 7. previous CS, 8. hypertensive disorders including
Data collectors recorded the indication exactly as it was eclampsia, preeclampsia and hypertension, 9. maternal
Elnakib et al. BMC Pregnancy and Childbirth (2019) 19:411 Page 4 of 11

disorders including hear problems and liver disease, 10. The intraclass correlation coefficient (ICC) was also
antepartum hemorrhage including placenta previa, 11. calculated (Eq. 2). This measure expresses the fraction of
infection and fever and, 12. an “other” category. variance of the dependent variable that is due to differ-
Structured face-to-face interviews with obstetricians ences between hospitals.
were administered by a trained researcher. A question-
σ2
naire comprising 40 close-ended questions was used to ICC ¼ ð2Þ
π2
guide the interview. Specifically, obstetricians were asked σ2 þ
about the preferred mode of delivery in their hospital, 3
decision-making processes, and perceived changes in
mode of delivery over time. They were also asked about Results
hospital level factors that may influence CS such as the Medical records
presence of incentives favoring CS deliveries – both ma- A total of 4357 records of women who gave birth during
terial and others, availability of medical protocols and the month of April 2016 were obtained in the 13 public
training, and the conduct of medical reviews or audits. hospitals in Assiut, Behera, Alexandria and Cairo.
Around 2% of medical records had missing data on
Statistical analysis mode of delivery. Of the 4252 records for which a mode
Obstetric risk factors highlighted in the literature and of delivery was recorded, CS delivery accounted for
for which data was available in medical records were an- more than half of deliveries (54.2%) (Fig. 2). Almost 10%
alyzed using univariable and multivariable multilevel lo- of medical records for CS deliveries had no medical indi-
gistic modelling. Two separate outcomes were assessed: cations listed. Around 49% of CS deliveries occurred be-
pre-labor CS and CS after onset of labor. The dataset fore onset of labor.
was hierarchical with 2 levels, patients as the first level A significant heterogeneity was observed in CS rates
and hospitals as the second level. The use of a random across the 13 hospitals with hospital-specific rates ran-
intercept in a logistic regression model allowed us to ging from a low of 22.9% to a high of 94.3% (Fig. 3).
cluster the effects of the patient’s characteristics on the Fig. 4 shows number of caesarean and vaginal deliver-
probability of undergoing a CS across hospitals. Preva- ies in the study hospitals by day of the week. The plot
lence odds ratios (OR) with a 95% confidence interval reveals that CS deliveries peaked on Saturdays (consid-
(95% CI) were obtained. The model is specified as fol- ered the first working day in the public sector) and were
lows (Eq. 1). lowest on Fridays (the first day of the weekend and con-
sidered a holy day), whereas for vaginal deliveries, there
Yij ¼ β0 þ b0i þ β1x1ij þ β2x2ij þ ⋯ þ βnxnij were no marked differences based on day of the week.
þ ɛ0i ð1Þ
Medical indications
Where Y is the probability of CS for individual j and Fig. 5 demonstrates the distribution of maternal and
hospital I; X are predictor variables, β is the estimated fetal indications for CS according to hospital records.
coefficient corresponding to X, and b0i is the random Almost half of all recorded medical indications were
intercept. previous CS (50%), followed by an “other” category

Fig. 2 Distribution of medical records across the 13 hospitals

Elnakib et al. BMC Pregnancy and Childbirth (2019) 19:411 Page 5 of 11

Fig. 3 CS rates in each of the study hospitals in April 2016

(13%), and fetal distress (9%). Notably, out of a total Obstetric profile of women undergoing CS in the study
of 1259 previous CS indications, 1047 did not have hospitals
any other accompanying indications listed. For the The obstetric characteristics of women delivering by CS
most part, there were no remarkable differences in vs those delivering vaginally are shown in Table 1.
the distribution of medical indications across the The intraclass correlation due to hospital accounted for
study hospitals. 26% of the variance in pre-labor CS, and 19% of the vari-
Overall partograph use was very low in the study ance in CS with labor onset. Table 2 presents results of the
hospitals. Availability and completion of a partograph risk factor analysis of CS with and without onset of labor.
was checked for all medical records. Only 397 of re- Maternal age at delivery was a strong risk factor for
cords (9.11%) contained a completed partograph, of CS among women who delivered by CS with onset of
which 216 were for CS deliveries and 127 were for labor; for a given hospital, women ages 35 and older had
vaginal deliveries. Among pre-labor CS deliveries, a 2.1 times the odds of CS delivery compared to women
partograph was available for 14.9% of the cases. younger than 21 (95% Confidence Interval [CI] 1.3–4.0),

Fig. 4 Number of CS deliveries performed by day of the week. ***Denotes p-value< 0.001 with regards to comparison with the day before
Elnakib et al. BMC Pregnancy and Childbirth (2019) 19:411 Page 6 of 11

Fig. 5 Distribution of medical Indications for CS by study hospital

and women 21–34 years had 1.7 times the odds of CS and augment labor was negatively associated with pre-
(95% CI 1.3–2.1) compared to women below age 21. labor CS (AOR 0.1, 95% CI 0.06–0.12), and so was the
Similarly, there was a strong association between age use of a partograph (AOR 0.3, 95% CI 0.1–0.8).
and pre-labor CS delivery. This association was strongest OR, odds ratio; AOR, adjusted odds ratio.
for women ages 35 and older (Adjusted OR [AOR] 3.9).
Among women who underwent labor, high gestational
Structured interviews with physicians in the study
age (≥37 weeks) was positively associated with CS (AOR
hospitals
1.9, 95% CI 1.3–2.9). This association was not present for
women who did not experience labor (AOR 1.05, 95% CI A total of 275 obstetricians in the study hospitals were
interviewed. Their characteristics are presented in Table 3.
0.71–1.56). The strongest risk factor for CS delivery was
Around 88% of respondents confirmed that they ob-
previous CS among multiparous women. This association
was strong for women who underwent labor (AOR 13.3) served an increase in CS rates in their respective hospitals
and 60% confirmed that some cases that are delivered by
and even stronger among women whose CS occurred be-
CS could have been delivered vaginally. Providers mainly
fore onset of labor (AOR 36.5). Interestingly, women who
were multiparous and had no history of previous CS had attributed the increase in CS to a rise in cases with medical
indications (71%) followed by maternal request for elective
significantly lower odds of delivering by CS, compared to
their nulliparous counterparts. Moreover, singleton births caesarean (42%), physicians’ personal preference (21%) and
were associated with decreased odds of CS compared to lastly reasons related to hospital systems and resources
(10%).1 When asked about indications most commonly re-
multiple births in unadjusted analysis (OR 0.8); nonetheless,
after adjustment, the odds ratio of CS delivery among sponsible for CS delivery, 91% answered “previous CS.”
women who delivered a singleton birth was 2.1 (95% CI Around 25% listed fetal status as a common medical indica-
tion, followed by fetal lie (18%), maternal factors (18%), pla-
1.0–4.4) in the presence of labor and 2.1 (95% CI 1.1–4.15)
in the absence of labor. The confidence interval, however, cental reasons (12%), and failure to progress (12%).2
overlaps the null value for the former. When asked specifically if obstetricians in their hos-
pital preferred a CS to vaginal delivery, 42% of respon-
Non-cephalic fetal presentation and eclampsia were
both strongly associated with CS mode of delivery. dents answered affirmatively. The main reasons for
These associations however were stronger for pre-labor 1
Multiple answers were allowed
2
CS deliveries. Further, oxytocin which is used to induce Multiple answers were allowed.
Elnakib et al. BMC Pregnancy and Childbirth (2019) 19:411 Page 7 of 11

Table 1 Characteristics of women undergoing Caesarean opportunities and 7% stated that these were not regular.
section delivery vs vaginal delivery in the study hospitals Additionally, 23% of respondents indicated that their
Characteristic N = 4183 hospitals did not receive medical audits or supervisory
Vaginal Delivery Caesarean Delivery visits from higher level agencies or authorities.
n = 1880 n = 2303
Maternal Age at delivery Discussion
Less than 21 357 (19.2%) 249 (11.4%) In this study, the average CS rate was 53%, but varied
21–34 1321 (71%) 1622 (74%) across hospitals ranging between 22.9 and 94%. Some
35 and above 184 (9.9%) 322 (14.7%) variation in CS rates and in the distribution of medical
Gestational Age
indications should be reasonably expected considering
inherent differences in the patient population case-mix
< 37 weeks 188 (10.8%) 365 (16.9%)
at each hospital as well as the size and nature of the
≥ 37 weeks 1559 (89.2%) 1798 (83.1%) hospitals (e.g. district versus teaching or university
Parity hospital3).
Nulliparous 502 (29.4%) 456 (21%) Inspection of medical indications indicated that CS
Multiparous 1206 (70.6%) 1721 (79%) was being performed in the absence of strong medical
Previous CS
justification. Across study hospitals, the most commonly
cited indications were previous CS, ‘other’, and fetal dis-
Yes 56 (3%) 1431 (65.2%)
tress. Two of these should not result in CS by default,
No 1787 (97%) 763 (34.8%) namely previous CS – for which a trial of labor after cae-
Multiple Gestation sarean is a well-recognized option – and fetal distress,
Singleton 1766 (95.1%) 2035 (91.9%) for which there are several interventions that can be
Multiple 92 (5%) 180 (8.1%) attempted before a decision is made to opt for CS [8,
Eclampsia
30]. We found very high rates of repeat CS which could
be behind the alarming increase in overall CS rates. Ac-
Yes 10 (0.53%) 101 (4.4%)
cording to the American College of Obstetricians and
No 1870 (99.5%) 2202 (96%) Gynecologists, previous CS should not be an indication
Fetal Presentation in the absence of any obstetric emergencies [31]. Yet,
Cephalic 1773 (95.6%) 1852 (86.5%) previous CS was the leading indication for CS in all
Non-cephalic 82 (4.4%) 290 (13.5%) study hospitals, and around 1047 CS deliveries only had
Onset of Labor
“previous CS” listed as an indication. Additionally, the
majority of interviewed obstetricians confirmed that
Yes 1852 (100) 993 (51%)
previous CS was a common indication motivating the
No 0 (0%) 954 (49%) choice of delivery. A multitude of studies have shown
that vaginal birth after caesarean (VBAC) is a safe op-
preferring a CS were doctors’ ability to schedule the CS tion, with good success rates and low associated risk
at their convenience (44%), the shorter duration of deliv- [32–34]. In several countries, a trial of labor after one
ery by CS compared to vaginal delivery (28%), inad- CS is recommended in an effort to curb the increase in
equate training of physicians in vaginal delivery (44%) CS rates [31, 35]. In this study, the VBAC rate consti-
and financial incentives (17%). tuted a meager 3% of deliveries with previous CS. It is
Asked whether there are standard guidelines for mode therefore important that physicians are encouraged to
of delivery in their respective hospitals, 39% stated that implement evidence-based obstetric practices, such as
there were none and 4% answered that they did not VBAC, instead of automatically opting for CS.
know of any. Additionally, more subjective indications, such as labor
In terms of training in CS, when asked if residents are abnormalities without a completed partograph and non-
expected to perform a minimum number of supervised reassuring fetal status or fetal distress without a docu-
CS deliveries before operating independently, only 45% mented fetal heart rate tracing or monitoring were
of participants indicated that their hospitals specify a commonly recorded as indications. In light of the low
minimum number of CS cases that a resident must per- rates of partograph use and low fetal cardiac monitoring
form under supervision before s/he is allowed to work in the study hospitals, indications such as non-
on his/her own. With respect to morning rounds, review reassuring fetal status for example seem to be largely
of management of high-risk cases or staff meetings in based on subjective clinician’s judgement instead of a
which residents can discuss deliveries with more senior
3
staff, 25% of physicians stated there weren’t any such University and teaching hospitals are tertiary care facilities
Elnakib et al. BMC Pregnancy and Childbirth (2019) 19:411 Page 8 of 11

Table 2 Obstetric risk factors associated with Caesarean section with and without onset of labor compared with vaginal delivery
Risk Factor CS with onset of labor CS without onset of labor (pre-labor)
OR (95% CI) AOR (95%CI) OR (95% CI) AOR (95%CI)
Maternal age at delivery
Less than 21 Ref Ref Ref Ref
21–34 1.5 (1.2–1.9) 1.7 (1.1–2.5) 1.7 (1.3–2.1) 1.63 (1.1–2.3)
35 and above 1.8 (1.3–2.5) 2.1 (1.3–4.0) 2.7 (2.0–3.7) 3.9 (2.3–6.5)
Gestational age
< 37 weeks Ref Ref Ref Ref
≥ 37 weeks 0.9 (0.7–1.1) 1.9 (1.3–2.9) 0.6 (0.5–0.8) 1.05 (0.71–1.56)
Parity and previous CS
Nulliparous Ref Ref Ref Ref
Multiparous with previous CS 30.6 (21.7–43.2) 13.3 (8.4–20.9) 32.7 (23.0–46.4) 36.5 (24.2–55.2)
Multiparous without previous CS 0.3 (0.2–0.4) 0.2 (0.1–0.3) 0.2 (0.2–0.3) 0.2 (0.1–0.2)
Multiple Gestation
Singleton 0.8 (0.6–1.2) 2.1 (1.0–4.4) 0.8 (0.6–1.2) 2.1 (1.1–4.15)
Multiple Ref Ref Ref Ref
Fetal Presentation
Cephalic Ref Ref Ref Ref
Other 4.0 (2.7–5.8) 8.5 (4.7–15.5) 3.2 (2.3–4.6) 10.7 (6.1–18.7)
Eclampsia
Yes 4.0 (1.9–8.6) 5.5 (1.9–15.4) 11.9 (6.0–23.7) 24.1 (10.1–57.6)
No Ref Ref Ref Ref
Oxytocin use
Yes 0.4 (0.2–0.7) 0.1 (0.06–0.12) – –
No Ref Ref
Partograph
Yes 0.4 (0.2–0.8) 0.3 (0.1–0.8) – –
No Ref Ref
OR odds ratio; AOR adjusted odds ratio

completed partograph. These findings seem to contrast reducing CS rates [8, 36], especially among women ex-
with what physicians had reported when asked about periencing delays in the progress of labor [37], a parto-
perceived reasons behind the increase in CS in their hos- graph may be a valuable tool in this context.
pitals. According to them, the primary reason for the Findings from our multilevel regression analysis are
rise in CS was the frequency of medical indications re- consistent with previous research on risk factors for CS
quiring a CS. However, the lack of objective medical in- and shed light on obstetric factors associated with CS
dications which unequivocally warrant this mode of delivery in this context. Regression analysis revealed that
delivery casts some doubt on that view. obstetric history strongly influenced mode of delivery.
With respect to investigations informing choice of Similar to other studies, previous CS and nulliparity
mode of delivery, a partograph, which is designed to were strongly associated with CS both among women
help obstetricians make the right decision for interven- who experienced labor and those who did not [38, 39].
tion in the right time was only done for 9% of all deliver- Nulliparity was found to be strongly associated with CS
ies and 14.9% of CS deliveries in which labor was delivery, which is worrisome because it indicates that
experienced. Lack of a partograph may indicate that women with no history of childbirth are increasingly de-
there was little effort being made to document, monitor livering by CS. Additionally, older maternal age was a
and assess progress of labor and other fetal conditions, risk factor for CS delivery. Even though childbearing be-
and that instead physicians were opting for CS by de- gins early for many Egyptian women, age at first birth is
fault. In light of evidence that a partograph can help in increasing which may raise concerns about further
Elnakib et al. BMC Pregnancy and Childbirth (2019) 19:411 Page 9 of 11

Table 3 Demographic characteristics of the sample (N = 275) supervisory visits from higher authorities. Regular super-
Characteristics Obstetricians vision, in the shape of staff rounds and meetings, can
Title, n (%) offer an opportunity for the review of deliveries and en-
Resident 116 (42.34)
able the provision of individual feedback to providers.
Staff rounds can also serve as a learning exercise
Assistant Specialist 56 (20.44)
through which younger obstetricians can learn from the
Specialist 63 (22.99) experiences of others. Such mechanisms should be used
Consultant/Professor 39 (14.23) to institutionalize a system of routine monitoring of phy-
Sex, n (%) sicians’ practices while serving as an accountability
Male 165 (61,57) mechanism to hold those who perform unjustified CS
Females 103 (38.43)
accountable. By requiring a mandatory second opinion,
hospitals may also be able to control the CS rates with-
Age, n (%)
out causing adverse effects on maternal and neonatal
20–29 61 (22.5) outcomes. Both obstetric peer review strategies as well
30–39 111 (40.96) as mandatory second opinion have been shown to re-
40–49 45 (16.61) duce CS rates in other settings [43, 44]. Some providers
50–59 41 (15.13) also viewed poor training in vaginal delivery as a reason
60+ 13 (4.80)
behind the tendency to resort to CS. This finding aligns
with other literature which indicates that loss of medical
Years of Experience, mean ± sd 11.16 ± 10.26
competence in attending a vaginal delivery is a driver of
increasing CS rates [45].
expansion in the CS rates [19]. Not surprisingly, obstet- Moreover, the finding that nearly 43% of physicians
ric risk factors such as non-cephalic presentation and are either not aware of the presence of standardized
eclampsia were associated with increased odds of CS de- guidelines in their respective hospitals or claim they do
livery. Gestational age was only associated with pre- not exist to begin with attests to the urgent need for
labor CS, but was not a risk factor for CS without onset dissemination of standardized clinical guidelines and for
of labor. In line with other studies, our analysis further their activation in hospitals. Unfortunately, available
confirms that partograph use and oxytocin are associ- national guidelines developed by the MoHP for Ob/Gyns
ated with decreased odds of CS [40–42]. are general and cover a broad set of topics including
In addition to medical and obstetric risk factors identi- antenatal care, delivery, post-natal care, pre-eclampsia,
fied from the analysis of medical records, interviews with among others. Further, they were last updated almost
obstetricians shed light on several provider-related 10 years ago. Hence, the need for updated national
drivers of CS. The analysis revealed three important fac- guidelines and evidence-based recommendations is
tors that could be contributing to the expansion in CS pressing, especially with respect to antenatal and intra-
rates: [1] a convenience incentive; [2] lack of supervision partum management of VBAC deliveries. Raising the
and training; [3] and absence of or lack of familiarity awareness of providers about the appropriate indications
with clinical guidelines. A little less than half of obstetri- for CS and the importance of advocating for vaginal de-
cians confirmed a personal preference for CS. Inter- livery among eligible women – including those with a
viewed physicians cited the shorter duration of a CS previous CS – can trigger practice changes that may re-
compared to a vaginal delivery as a reason for why CS duce the incidence of non-medically indicated caesarean
might be favored. This combined with the ability of doc- delivery.
tors to decide on the timing of the delivery make CS a Finally, maternal request was cited by 42% of physi-
more convenient option for physicians. That most CS cians as a reason for the increase in CS rates. Unfortu-
deliveries in this study took place on a Saturday, which nately, maternal request is not readily identifiable in
is the first working day of the week where most staff are medical records and women were not asked about this
available, and rarely on Friday – which is considered a in our study. Hence, we were not able to verify this
holy day and a day of rest, is evidence that physicians statement.
may prefer CS owing to scheduling preferences. In com-
parison, vaginal deliveries were equally likely to occur at Limitations
any given day of the week. Study hospitals were not randomly selected and are not
Our study also pointed to the lack of training and nationally representative, which limits the generalizability
performance supervision in the hospitals, both within of our findings. Additionally, the use of medical indica-
the hospital through obstetric peer review as well as tions has its limitations. For one, there may be a lack of
from outside the hospital through medical audits and uniformity in the definition of medical indications and
Elnakib et al. BMC Pregnancy and Childbirth (2019) 19:411 Page 10 of 11

variability in record keeping across study hospitals. Also, Availability of data and materials
false reporting of complications and exaggeration of med- Data supporting the results of this paper can be found in the Population
Council database and can be shared on reasonable request.
ical indications to justify a CS procedure are possible. Our
analysis still reveals that the most common medical indi-
Ethics approval and consent to participate
cations, particularly previous CS, do not lend strong med- This study was approved by the Population Council’s Institutional Review
ical justification for CS delivery, and that commonly Board and the Ethics Committee of the Egyptian Ministry of Health and
recorded medical indications were more likely to be sub- Population. Informed consent was obtained from each of the obstetricians
interviewed in this study. Those who agreed to take part in the study were
jectively defined and based on a clinician’s judgement. asked to sign the informed consent form before the interviews. Participants
Another limitation is that medical records lacked who agreed to participate but were unable or unwilling to sign were asked
information on maternal request, which would have pro- to give verbal consent in the presence of a witness. Both the interviewer
and the witness had to provide their signature indicating that the person
vided a more complete picture of drivers of CS in the has agreed to participate. Both IRB committees approved this consent
study hospitals. Furthermore, this study was only con- protocol. For medical record data, permission was obtained from the health
ducted in public hospitals, which does not offer much facility to access patients records. Throughout data abstraction, no personal
identifiers were recorded; instead identification code numbers were used.
insight on practices in private facilities. This was due to
difficulties in obtaining approval to access medical re-
Consent for publication
cords in private facilities. It is noteworthy that CS rates NA
tend to be higher in private facilities in Egypt [19], so we
expect non-medically indicated CS to be an even greater Competing interests
problem in private hospitals. The authors declare that they have no competing interests.

Author details
Conclusion 1
Department of International Health, Johns Hopkins Bloomberg School of
Over-medicalization of the birth process in Egypt as Public Health, 615 N. Wolfe Street, Baltimore, MD 21205, USA. 2Population
Council, Cairo, Egypt. 3Independent Consultant, Reproductive Health
manifest in overuse of caesarean delivery constitutes a Consultant, Cairo, Egypt.
critical public health issue that merits immediate action
due to the unnecessary strain CS places on the health Received: 12 December 2018 Accepted: 14 October 2019
system. Our study presented an in-depth analysis of clin-
ical and non-clinical factors that are associated with CS
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