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BackgroundCaesarean section (CS) is an important lifesaving intervention that can reduce maternal and newborn morbidity and mortality. The dramatic increase in CS rates globally has prompted concerns that the procedure may be overused or used for inappropriate indications. In Egypt, CS rates are alarmingly high, accounting for 52% of all deliveries. This study sought to (1) explore indications and risk factors for CS in public hospitals in four governorates in Egypt and (2) examine health care provider factors impacting the decision to perform a CS.MethodsWe reviewed medical records for all deliveries that took place during April 2016 in 13 public hospitals situated in four governorates in Egypt (Cairo, Alexandria, Assiut and Behera), and extracted information pertaining to medical indications and women’s obstetric characteristics. We also interviewed obstetricians in the study hospitals to explore factors associated with the decision to perform CS.ResultsA total of 4357 deliveries took place in the study hospitals during that period. The most common medical indications were previous CS (50%), an “other” category (13%), and fetal distress (9%). Multilevel analysis revealed that several obstetric risk factors were associated with increased odds of CS mode of delivery – including previous CS, older maternal age, and nulliparity – while factors such as partograph completion and oxytocin use were associated with reduced odds of CS. Interviews with obstetricians highlighted non-medical factors implicated in the high CS rates, including a convenience incentive, lack of supervision and training in public hospitals, as well as absence of or lack of familiarity with clinical guidelines.ConclusionA combination of both medical and non-medical factors drives the increase in CS rates. Our analysis however suggests that a substantial number of CS deliveries took place in the absence of strong medical justification. Health care provider factors seem to be powerful factors influencing CS rates in the study hospitals.

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a b s t r a c t a r t i c l e i n f oKeywords: Egypt Family planning Public health services Reproductive rights Young married women Objective: To assess supply and demand of family planning services from a reproductive rights perspective among young married women (YMW) in Egypt. Methods: Data sources related to family planning included structured interviews with service providers (n = 216); an inventory of equipment and supplies (n = 40); exit interviews with YMW (n = 147); and focus group discussions (n = 12) with YMW, husbands, and mothers and/or mothers in law. YMW, husbands and mothers in law were not necessarily related. Results: Although family planning services were readily available and affordable, YMW had limited access to information and services. Shortfalls were noted regarding respect for privacy, choice of family planning method, access to fertility services, and premarital counseling. Few YMW had sufficient autonomy to make informed reproductive decisions. Effective accountability mechanisms and processes for redress were also lacking. Conclusion: Implementation of a rights-based approach and structural changes to family planning service delivery are recommended to empower YMW in Egypt to demand and exercise their reproductive rights.

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