Seven children in ten born via C-section

Statistics released in September by CAPMAS, the government’s statistics agency, showed that of the 2.1 million babies born in Egypt in 2021, about 72% were delivered via C-section. The rate is around seven times the frequency of C-section births recommended by the World Health Organization. According to the WHO, “maternal mortality and morbidity is approximately five times greater with cesarean than with vaginal birth.”

Civil society representatives, mothers, doctors, and officials described to Mada Masr a range of underlying factors that result in the high rate of cesareans, including poor access to information, a chronic lack of resources, and the medical sector’s scarce salaries, which push doctors to recommend a short, well-compensated cesarean section rather than a 16 to 18-hour vaginal birth.

Even though the government promises to right some of these issues in their containment strategy to combat C-sections’ skyrocketing rates — proposing financial incentives for hospitals that plan to increase their rate of vaginal births and a doula training program to relieve pressure on physicians — the measures put in place have been scant so far.

Civil society workers focusing on the issue anticipate that the medical environment around newborn deliveries in the country will remain obscure and uncomfortable for most pregnant people.

Doctors' greed or lack of availability?

A person working on the Health Ministry’s C-section campaign, speaking to Mada Masr on condition of anonymity, described the issue as one of “doctors’ greed for easier profitability.”

But in Egypt, the medical system suffers from persistent low capacity, which compromises doctors’ ability to supervise vaginal births while maintaining essential quality care. Early this year, the Doctors Syndicate released an alarming report on the medical staff shortage sweeping the nation’s health care facilities, saying that the availability of Egyptian doctors stands at just 8.6 doctors for every 10,000 patients, or only “one third of the global standard.”

According to the same report, the average pay for Egyptian doctors is LE3,700 per month (currently under US$190), while the average pension after completing 35 years of working in public hospitals amounts to just LE 2,300 (under $120).

C-sections represent a legally safer option for doctors

These conditions are bleeding doctors dry and pushing them to pursue more hospitable work environments in health sectors abroad. “More than 11,000 doctors resigned from their government jobs only between 2019 and 2022,” the syndicate said.

Given such working conditions, the relatively high fees doctors can accrue through C-sections make them the more favorable option. According to Health Ministry Maternity and Childcare General Department Head Amal Abdel Hai, a vaginal birth at a government hospital costs around LE175 ($9), whereas C-section surgeries at private hospitals are estimated to cost between LE10,000 and LE40,000 (roughly $500 to $2,000).

Low staffing capacity also increases the time and cost efficiency of C-sections. “The time consumed by a doctor overseeing a single vaginal birth case equals the time spent performing around 10 C-section operations,” Abdel Hai said, while Cairo University Gynecology Professor Hossam al-Shenofy told Sada al-Balad last month that “a C-section surgery is a scheduled one-hour operation, as opposed to natural birth, which lasts on average between 16-18 hours.”

Given that C-sections are considered preferable in this context, many doctors end up untrained in handling vaginal deliveries, noted Farida Mahgoub, founder of the Kayan Foundation’s Ending Obstetric Violence Initiative. Most medical facilities “cannot afford” to assign a doctor to a single patient who would consume at least a full day of their capacity, said Abdel Hai.

The legal threat of malpractice

A lack of medical accountability legislation also means that, aside from the extra pressure of performing a time-consuming operation for a lower fee and with limited support staff availability, C-sections represent a legally safer option for doctors, Abdel Hai explained to the press.

“It takes the doctor a brief visit to the hospital to conduct a C-section, and then they leave. In that case, any further health complications that occur in their absence would not be legally considered malpractice. On the other hand, natural births’ longer average durations leave doctors more vulnerable to legal questioning in case of complications.”

Speaking to Mada Masr, Abdel Hai explained that, at the moment, Egyptian doctors are prosecuted under criminal law if accused of malpractice. The possibility of immediately ending up in custody if sued under criminal law makes doctors reluctant to undergo the lengthy and demanding natural birth process.

“But this also means that women who undergo C-sections have lower chances of seeking legal action in cases where medical malpractice does actually occur,” said May al-Shamy, founder of the Stop Unnecessary Cesareans initiative.

Lack of knowledge and misinformation

Medical practitioners’ work environments have unaddressed and deeply entrenched issues that ultimately have a knock-on effect that compromises pregnant people’s experience of delivering children, their personal health, and their prerogative to go into childbirth with informed agency over the process. For the most part, women don’t really “go for” cesareans, Shamy said; it’s more that they are led to believe it’s their only option.

Fear of pain is the number one driver of high preference of C-sections among women, said Mahgoub, noting that “there are medical protocols for handling all the complications of vaginal birth, including variations of pain management” of which many pregnant people are not made aware, as happened with Nahla, the new mother from Port Said who only discovered that anesthesia was available to her after delivery.

At least part of the responsibility for this lies at the door of practicing physicians. Some refrain from fully informing their patients of all the stakes, said Mahgoub, while Shamy describes doctors inducing fear in pregnant people regarding the impact of vaginal birth on the patient’s sex life in the case of episiotomy: the surgical widening of the vaginal canal to facilitate the baby’s exit. According to the person working in the Health Ministry’s C-section campaign, doctors sometimes “exaggerate the complications of vaginal birth or conceal those entailed in opting for C-section.” Shamy notes however, that widespread “sexual illiteracy” makes it easier for doctors to mislead their patients.

I didn’t know that my husband wouldn’t be allowed in the room.

Misinformation can compromise the medical experience even of those who undergo C-sections due to medical necessity. Shams, a 34-year-old mother residing in Cairo, underwent the major surgery in October as she suffered excessive bleeding six weeks before her due date. “I wasn’t told much, except that I immediately needed to have a C-section,” Shams said, recalling “simple things” she would have preferred to be acquainted with beforehand.

“I didn’t know that my husband wouldn’t be allowed in the room, or that I would wake up from the surgery and not see my baby for a couple of hours.” It was the same story with breastfeeding, Shams said, describing waking up to find baby formula placed on the table next to her: “There was no conversation about it.”

These might all be the standard steps for my case that make sense for the doctor, she reiterated, “but I wasn’t made aware of any of them beforehand.”

Going into the C-section surgeries blind in this way is a major health concern, said Mahgoub. “C-sections are actually major surgeries with linked complications on the baby’s health and the mother’s, especially when it comes to breastfeeding.”

Government to lower number of C-sections

To try and remedy the situation, the Health Ministry is setting up a program of measures directed at improving patients’ medical experience of birth. The government is working on raising public awareness about the dangers of C-sections in order to protect women’s and children’s health, Health Minister Khaled Abdel Ghaffar said in a phone-in TV interview last month. The minister also mentioned a financial incentives strategy that aims to encourage hospitals to offer vaginal births as opposed to “unnecessary” C-sections.

A training program is intended to qualify doulas across government hospitals in order to assist with the provision of care for vaginal birth cases.

So far, however, the steps that have been carried out are slight. After September’s statistics revealed the high frequency of cesarean deliveries in Egypt, the Health Ministry quickly circulated directives, of which Mada Masr reviewed a copy, instructing the formation of permanent committees in all hospitals with the role of determining and approving the medical necessity of all scheduled C-sections.

This is intended to go alongside an initiative that should see hospitals undertake more comprehensive reporting to the government about the number of cesareans as opposed to vaginal deliveries.

Civil society initiatives focused on calling out violations of women’s health rights have generally welcomed the Health Ministry’s move. “It is a great start for sure,” Shamy said. “But as the ministry hopes to increase awareness of the complications of C-section surgeries, we are still missing relevant data. The recent statistics are the first in seven years. How would we be able to put together awareness campaigns when we lack updated data on the volume of the issue at hand?”

And in the meantime, many mothers with first-hand experience of the health system, like Nahla, have made their own decision. Into the third month of her second pregnancy, Nahla said she is not not up for experimenting with herself this time.

“I’ll never give vaginal birth a chance again.”