➡️Background

Significant improvements in clinical obstetric care and increased safety in surgical procedures have been observed over the past three decades. This appears an increase in cesarean sections in Egypt, like a global trend. The number of women who deliver by Cesarean section has increased steadily in Egypt over the last three decades, from 4.6% in 1992 (1) to 51.8% in 2014 (2).

Cesarean birth is associated with short- and long-term risks that can extend many years beyond the current delivery and affect the health of the woman, the child, and future pregnancies. As with any surgery, cesarean section is associated with short- and long-term risks. These can extend many years beyond the current delivery and affect the health of the woman, the child, and future pregnancies. Cesarean section increases the likelihood of requiring a blood transfusion, the risks of anesthesia complications, organ injury, infection, thromboembolic disease, and neonatal respiratory distress, among other short-term complications. Cesarean section has been associated in the long term with an increased risk of asthma and obesity in children, and complications in subsequent pregnancies, such as uterine rupture, placenta accreta, placenta previa, hysterectomy, and intra-abdominal adhesions, with the risk of these morbidities progressively increasing as the number of previous cesarean deliveries increases. These risks are higher in women with limited access to comprehensive obstetric care, and they require careful consideration in settings that lack the facilities and capacity to conduct surgery safely or to treat surgical complications. High rates of cesarean section are associated with substantial health-care costs (3).

The factors contributing to the rise in cesarean section rates are complex, and identifying interventions to address them is challenging. Factors associated with cesarean births include changes in the characteristics of the population such as increase in the prevalence of multiple pregnancies, assisted reproduction, and increase in the proportion of nulliparous women with advanced age. Other non-clinical factors such as women increasingly wanting to determine how and when their child is born, generational shifts in work and family responsibilities, physician factors, increasing fear of medical litigation, as well as organizational, economic and social factors have all been implicated in this increase (4).

For nearly 30 years, the international health-care community has considered the ideal rate for cesarean section to be between 10% and 15%.  WHO released a statement summarizing the results of systematic reviews and analysis of the available data on cesarean births. Considering the evidence, the panel of experts convened by WHO concluded in the statement that, at population level, cesarean section rates higher than 10% were not associated with reductions in rates of maternal and newborn mortality. The statement notes, however, that the association between cesarean section rates and other relevant outcomes such as stillbirths, maternal and perinatal morbidity, pediatric outcomes and psychological or social well-being could not be determined due to the lack of data on these outcomes at the population level. The scarcity of data is a limitation of this evidence that needs to be borne in mind when interpreting the WHO statement (9).

should be made to provide cesarean sections to women in need, rather than striving to achieve a specific rate.

This is the first national guideline on non-clinical interventions to reduce cesarean sections – i.e. those performed in the absence of medical indications. Non-clinical interventions in this guideline refer to those interventions applied independently of a clinical encounter between a particular provider and patient in the context of patient care.

➡️Why this guideline is needed

The rise in cesarean section rates is a national problem. The causes of the increase are multiple. Changes in the characteristics of the population, such as the increase in assisted reproduction, advanced maternal age, and multifetal gestation, have been cited to contribute to the rise. Other factors such as differences in style of professional practice, increasing fear of medical litigation, and organizational, economic, social, and cultural factors have all been implicated in this rising tide.

We expect this guideline to help clinicians and other health-care professionals to reduce rates of cesarean sections. Effective implementation of this guideline will contribute to achievement of the United Nation’s Sustainable Development Goal 3 (“Ensure healthy lives and promote well-being for all at all ages”) by improving the quality of care during childbirth and reducing complications, disability and death associated with cesarean births, particularly in settings that lack the facilities and/or capacity to properly conduct safe surgery (10).

➡️Target audience

The primary audience for this guideline includes health-care professionals namely obstetricians, midwives, nurses, and general medical practitioners, as well as managers of maternal and child health programs and public health policymakers in Egypt.