Medical and non-medical reasons for cesarean section delivery in Egypt: a hospital-based retrospective study

Shatha Elnakib, Nahla Abdel-Tawab, Doaa Orbay, Nevine Hassanein, Shatha Elnakib, Nahla Abdel-Tawab, Doaa Orbay, Nevine Hassanein

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: Caesarean section; Egypt; Indications; Maternal health; Reproductive health.

Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
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
Fig. 2
Fig. 2
Distribution of medical records across the 13 hospitals
Fig. 3
Fig. 3
CS rates in each of the study hospitals in April 2016
Fig. 4
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
Fig. 5
Fig. 5
Distribution of medical Indications for CS by study hospital

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