Egypt leads the world in C-sections, but can the tide be turned?

At the end of August, Egypt’s Ministry of Health/MoH launched an initiative to promote vaginal/normal birth and reduce cesarean deliveries. At the same time, Hamida’s two new grandchildren were both born by C‑section at private facilities.

All of Hamida Abdel Wasie’s seven children were delivered vaginally, unlike her sons’ wives, who all had their babies by C‑section.

The 68 year old grandmother doesn’t know when the shift happened from “the way God created us” to surgery. “We used to call it ‘slitting the belly,’” she told Al Manassa, adding that in her generation “a woman who delivered by C‑section would make us feel sorry for her.”

Egypt recorded a 10% C‑section rate in 2000. The rate then climbed steadily as physicians increasingly opted for surgery without medical necessity, reaching 28% in 2008 and continuing to surge to 72% by 2022. That spike pushed the MoH to launch an initiative to bring down the C‑sections rates.

Opting for a C‑section

What Hamida considers the advantages of normal birth holds no appeal for her middle son’s wife Asmaa Fahmy, who has had three C‑sections and believes that “a cesarean saves women from the pain of labor,” she told Al Manassa.

Asmaa, now 25, had her first child at age 17 at Al‑Galaa Hospital. “My mother told the doctors that we wanted a C‑section because I was young and wouldn’t bear the contractions,” she said, adding that she still doesn’t know whether the surgery happened because of her mother’s insistence or for medical reasons.

Asmaa considers herself fortunate to have had all three surgeries before the new rules governing C‑sections came into effect. Other expecting women are now terrified of the impact of “the new initiative.” 

One is Walaa Gamal, 30, who told Al Manassa that she has “a phobia of normal birth and can’t imagine going through it.”

For Walaa, it isn’t just the pain. At the local public health center for a tetanus shot in her sixth month, she said “the bigger problem is that vaginal birth damages the woman’s body, and now doctors also take the easy way with routine episiotomy.”

Sonia Mostafa, who previously delivered three of her children vaginally, recalled how social‑media chatter about the perks of C‑sections influenced her. “I gave birth three times vaginally and got hemorrhoids with those deliveries. Ten years after my last birth, I got pregnant again. I found women praising C‑sections by the time and thought, why not?”

When the doctor told the now 37‑year‑old Sonia that he would prefer C‑section “because of age,” she didn’t object. But today, one year after delivery, she admits that “a C‑section is the worst thing a woman can go through in her life.” She added, “Young women celebrate it thinking its problems are minor. But after trying both, I realized they’re happy only because they’ve never experienced a normal birth. You deliver and then just get up and walk.”

Leading the world in C‑sections

The 2021 health survey found that 7 out of every 10 live births in the previous five years were C‑section. It also found that women who gave birth in private facilities had a C-section at a much higher rate (81%) than their counterparts in public facilities.

Egypt’s rise tracks a global increase in cesareans, but the MoH says the numbers put Egypt first worldwide. The World Health Organization/WHO estimates the acceptable upper range for C‑sections at 10 to 15%; Egypt exceeds that by 57 percentage points.

Medical and rights groups, in Egypt and globally, have adopted a critical stance towards non‑indicated cesareans. A procedure once reserved to save the life of the mother or unborn child when labor fails to progress has turned into the default. Overuse is linked to heightened risks for children, including autism and obesity.

In response, the MoH’s latest initiative imposes oversight measures on private facilities with a C‑section rate greater than 70%. It requires detailed monthly statistical reports listing total deliveries, the share of cesareans, and their classification according to the Robson system.

Private facilities must justify each C‑section, using data from the partograph, which helps clinicians make timely, evidence-based decisions and reduce unnecessary surgery.

Earlier efforts

The new initiative is not the first; in 2022, the MoH issued non-binding recommendations to curb cesareans. What sets the current effort apart is that it mandates oversight of private facilities through periodic reporting and medical justifications for every C‑section. The question is how the ministry will compel these facilities to comply, and what guarantees that the reporting won’t be fabricated.

Dr. Abla Al‑Alfy, deputy health minister and chair of the National Population Council, stressed that the ministry will enforce digitization. “There will be a system linking the ministry to private centers to record case progress. This will enable monitoring birth plans and how centers are following the clinical guidelines,” she told Al Manassa.

She added that “specialized committees of professors and consultants will make unannounced inspections to compare random samples of cases logged in the system against submitted reports.”

Gradual decline

Al‑Alfy acknowledged that the ministry’s target, tied to a time frame ending in 2027 for the national strategy to support normal birth, will be difficult to achieve. She explained that during this period the ministry is “aiming for a gradual drop. By the end of 2025 we want to reach 50% C‑sections in public hospitals, and bring first‑birth cesareans down to 40%.”

“By late 2026,” she continued, “we want 60% of births to be vaginal, with first‑birth cesareans down to 35%.” The final 2027 target is “40% for women with multiple prior C‑sections and 30% for first births.”

For private clinics, she said the benchmarks are “60% C‑sections versus 40% vaginal by the end of 2025; 50% in 2026; then 40% C‑sections by the end of 2027.” She was confident that “if we hit those targets, it will be easy to reach the WHO’s 10 to 15%.”

To get there, Al‑Alfy said, the ministry’s strategy rests on six pillars: “training; strengthening midwifery; providing needed equipment and medications; raising community awareness through family counseling at all facilities; supporting the role of the birth companion/doula; and scientific monitoring, oversight and digitization.”

Fixing the paperwork or raising prices

By contrast, Ahmed Mahrous, an ob‑gyn in Sohag who owns a birth center, rejects the “villainizing of gynecologists.” He describes the initiative’s push for vaginal births at private centers as “further restrictions on a situation we’re barely coping with.” He also conceded that “the long‑term harms of C‑sections are many, but in the moment you spare yourself the headache and move the case along.”

Mahrous doubts the ministry’s measures will dissuade private facilities. “The paperwork will look perfect,” he said. “But it’s all in the doctor’s hands.”

Outlining other likely responses if centers don’t “fix” the paperwork, he said, “Those who stick to vaginal births will raise prices so they can hire trained nurses, and get a fee equal to a quarter or half of their effort.”

He pointed to the effort vaginal births demand for little recompense. He gets 3,000 pounds for a vaginal delivery, although a fair price would be between 10,000 to 15,000 pounds to account for “the doctor time staying with a case for eight to twelve hours, and bringing in a pediatrician and an anesthetist.” That, he said, “is still below the global rate.”

Prices vary by location, but vaginal birth is generally cheaper because C‑section is a surgical intervention. Mahrous expects most centers to stick to surgery at the same rate “We’ll wait to see where things land. Even if they shut us down, we’ll look for work abroad or switch careers.” He said he is unhappy with the current situation “I’ve been in business for ten years and still I don’t make 1,500 dollars a month,” a figure he expects will drop further if he shifts to vaginal births because of the longer time it takes, and trained staff it requires.

Price isn’t Mahrous’s only concern. He argued that obstetricians “work under threat,” and forcing them to favor vaginal births will increase that risk because vaginal deliveries “require mental alertness and hours of monitoring mother and baby.” 

Article 28 of Chapter Five of the Medical Liability Law, passed in April, sets a fine of no less than 10,000 pounds and no more than 100,000 for anyone whose medical error causes proven harm to a patient. The penalty rises to imprisonment for one to five years and a fine of no less than 500,000 pounds and no more than 2 million pounds, or one of those two penalties, if the offense results from gross medical error.

Dr. Al‑Alfy, however, sought to reassure doctors handling vaginal births, emphasizing that adherence to the clinical guidelines is their protection from liability. She noted that the law calls for expert committees to review medical liability cases, and that these committees “will base their opinions on whether the physician followed the guidelines and whether the reported complications are listed in those guidelines.”

Reproductive health care

Dr. Alaa Ghannam, who heads the right‑to‑health unit at the Egyptian Initiative for Personal Rights/EIPR, dismissed Mahrous’s comments as “promoting the commodification of healthcare,” insisting that “there is no justification for accepting a C‑section except for medical reasons.”

Ghannam said reducing C‑section rates depends on improving the quality of care women receive from the start of pregnancy through delivery. That aligns with an EIPR statement that advocates viewing the rise in C‑sections as “a symptom of a broader issue relating to the quality of maternal healthcare services.”

Pregnant with her second child, Shaimaa Ali agreed. She is attending a local public health center after using a private clinic for her first.

“I’m in my eighth month now and still don’t know the sex or weight of the baby. The doctor told me their device doesn’t measure weight,” said the expecting woman in her forties.

Yasmin Farag, a nurse at the Bahtim Health Center, told Al Manassa, “Pregnant women come monthly for follow up and counseling. In the sixth month they get a tetanus shot. Near delivery, we talk to them about birth exercises and how to breastfeed.”

Shaimaa doesn't deny getting these services, but she still considers them “way below what a private clinic provides.”

Shaimaa and other women expecting to deliver in the last quarter of 2025 are due to test the Health Ministry’s attempt to reduce non‑indicated C‑sections. By year‑end, the initiative is expected to yield its first results. Then we will see whether Egypt joins countries that managed to cut C‑section rates, such as Brazil, or continues to cut open women’s abdomens.