Elsevier

Health Policy

Volume 69, Issue 3, September 2004, Pages 273-281
Health Policy

Determinants of caesarean section in Egypt: evidence from the demographic and health survey

https://doi.org/10.1016/j.healthpol.2004.05.006Get rights and content

Abstract

This paper examines the impact of near birth complications and socio-demographic, healthcare and spatial characteristics of caesarean section in Egypt, using data on 4032 births from the 2000 Egypt Demographic and Health Survey. The hospital caesarean section rate was 22% in Egypt. Fever/vaginal discharge around delivery, birth weight, mother’s age and education, birth order, residence and antenatal visits were important determinants of caesarean section. Variations by place of delivery were evident, although complications were more significant determinants of caesarean section in public settings and demographic characteristics were more important in private facilities. Unexpectedly, long labour and bleeding around delivery were not associated with caesarean section, particularly, in private hospitals. In view of the high and rising caesarean section rate in Egypt, monitoring the quality of maternity services in Egypt is imperative. An investigation of the forces sustaining the differential in determinants by place of delivery is needed.

Introduction

The number of caesarean section (c-section) deliveries has been growing rapidly in many countries [1], [2], [3]. Recently, both health professionals and researchers expressed concern about the rise in c-section, with some referring to it as an emerging ‘global epidemic’ [4]. The increased practice of c-section in many developing countries is often necessary on medical, and perhaps social, grounds, leading to reduced maternal and infant morbidity as well as mortality. However, c-section deliveries do carry high health risks [5], [6] and lead to women’s discomfort after birth [7]. They may also impact the health care system negatively in term of resource use as compared to normal deliveries [5], [6]. Studies in the UK [1], [8], US [2], [9] and South America [3] suggest that concerns about the recent rise in c-section deliveries are well founded. While some countries have succeeded in controlling the rise in c-section [10], [11], others continue to have high rates, as proportions of all deliveries [9], [12].

Few studies have examined c-section rates in the Arab region. Most were based on small samples from hospital registers [13], [14], [15], owing perhaps to the lack of reliable administrative records at the national level. These studies as well as recent evidence from population-based data suggest that c-section rates are increasing in this region [16], [17], [18], and that uncertainty exists about their proper use in some contexts [17]. Specifically, Egypt and Lebanon stand out as having unusually high (over 15%) hospital rates of c-section as compared to other countries in this region [17], and that these rates, at least in Egypt, have been increasing over time [18]. This is surprising in light of the fact that home-births still constitute about half of all deliveries in Egypt [19]. With improved access to obstetric care, especially in rural areas, it is possible that c-section deliveries will increase further. As pointed by [20] and the US Department of Health and Human Services in Healthy People 2010 (see, [9]), c-section rates over 15% are worrying as they do not necessarily improve maternal or infant health.

This study presents the most recent estimate of c-section delivery in Egypt and examines the association of reported complications around delivery and socio-demographic, healthcare and spatial characteristics of women with c-section, using data from the latest Demographic and Health Survey. Establishing macro level prevalence rates of c-section is of vital importance from a policy perspective. Policy-makers as well as practitioners need to know macro c-sections rates, with a thorough understanding of the medical and non-medical determinants affecting the prevalence of the practice, in order to design reproductive health programs and policies aimed at achieving better quality of care, and hence reducing maternal deaths and morbidity.

Section snippets

Materials and methods

The study is based on data from the 2000 Egypt Demographic, Maternal and Health Survey (EDHS) conducted by Egypt’s Ministry of Health and Population, the National Population Council in collaboration with Macro International. The EDHS is one of many demographic and health surveys conducted in many developing countries since the mid 1980s with fairly standardized instruments, training and interviewing procedures, and are known for providing good demographic data. A national representative sample

Results

Table 1 presents the sample characteristics and the proportion of women reporting c-section delivery. The hospital-based c-section rate was 21.9% overall. The proportion of c-section was significantly higher among women reporting high fever or smelly discharge around the time of delivery (P = 0.000), possibility indicating a reproductive tract infection, as well as among women reporting very low or heavy birth weights (P = 0.000). Duration of labour, reports of excessive bleeding and multiple

Discussion and conclusions

This study examined the impact of near birth complications and socio-demographic, institutional, and spatial factors on c-section in Egypt, using data from the most recent demographic and health survey. The findings from the multivariate analysis showed that fever/vaginal discharge around delivery, heavy birth weight baby, older maternal age, low birth order, higher maternal educational level, urban residence and higher number of antenatal visits were important determinants of c-section. In

Acknowledgements

This paper is part of a larger regional research project on Changing Childbirth in the Arab Region, sponsored by the Centre for Research on Population and Health at the American University of Beirut with support from the Wellcome Trust and Mellon Foundation. We thank Dr. Karima Khalil for her helpful comments and suggestions on an earlier draft of this manuscript.

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