Recommendations on The Clinical Interventions For The Prevention of The Primary Cesarean Section
- Introduction
Cesarean section (CS) rates have increased dramatically worldwide, changing the surgical operation from a lifesaving intervention for high-risk and difficult deliveries to a routine surgical procedure. According to the WHO, the global CS rates tripled from 7% in 1990 to 21.1% in 2021, with projections indicating its rise to 28.5% by 2030 [1].
While medically indicated CS prevents maternal and neonatal mortality and morbidity in complicated deliveries, its overuse, without medical indication, exposes mothers and infants, to unnecessary risks and complications and also strains healthcare systems. In fact, studies have shown a significant increase in the maternal and neonatal mortality and morbidity with higher CS rates due to the short‐ and long‐term effects it poses to the mother, baby, and the subsequent pregnancies risks [2].
Egypt is witnessing a skyrocketing rate of CS. In 2014 Egypt ranked 4th worldwide after Dominican Republic, Brazil and Cyprus with a CS rate of 51.8% [3]. This rate is ever increasing and currently Egypt ranks first with the highest CS rate worldwide reaching 72.2% In 2021 [4] far exceeding the WHO recommended and acceptable CS rate which is around 15% above which there were no proven advantages of decreased maternal and neonatal mortality and morbidity over normal VD [5]. The rapid escalation is particularly pronounced in private health facilities, where rates have reached as high as 81% highlighting the urgent need for targeted interventions to address both medical and non-medical drivers of CS in Egypt.
CS increases maternal risks of hemorrhage (intrapartum and postpartum hemorrhage), infections (genital, UT and surgical site infections), organ injury (UT and GIT injury), TED (DVT and pulmonary embolism), anaesthetic complications and ileus on the short term. On the longer term there is higher incidences of placenta previa, placenta accreta spectrum, uterine rupture, hysterectomies and infertility with the development of chronic conditions like endometriosis, pelvic pain, and surgical adhesions [2].
For the neonatal and child health, CS without labor deprives infants of the physiological adaptations critical for extrauterine transition. The short-term consequences include: higher rates of respiratory distress, NICU admissions, and breastfeeding delays. In the longer-term; there is an altered gut microbiome development which increases the risks for non-communicable diseases like obesity, asthma, allergies, and type 1 diabetes. Childhood obesity rates are 40% higher in CS-born children due to microbiota dysbiosis [2].
For the health system efficiency, reducing CS rates is cost saving and allows better resource allocation both in consumables and in man power as it frees operating rooms and staff for high-need emergencies [2].
Reducing unnecessary CS rates is not merely a clinical concern but a multifaceted public health priority. It requires coordinated action, including the implementation of evidence-based clinical guidelines, public and professional education, and systemic reforms to address financial, personal and institutional incentives that may favor surgical delivery over vaginal birth.
This guideline responds to the WHO call for targeted strategies to reverse CS overuse and is aligned with Egypt’s recent policies of improving women’s and strategies for health system reform