The Egyptian Initiative for Personal Rights (EIPR) has received with close attention the recent announcement by the Minister of Health, imposing new standards to promote natural childbirth and reduce unnecessary caesarean sections. While we welcome the ministry's efforts to address the crisis of rising rates of non-essential caesarean deliveries,

EIPR believes that no tangible improvement in these rates can be achieved without a comprehensive

implementation plan. This plan should include increased investment in health in general, and particularly in maternal

and childbirth care, grounded in women's dignity and their rights to natural childbirth, and developed in collaboration

with civil society organisations, including the Doctors' Syndicate, medical schools, and the Egyptian Society of Obstetrics

and Gynaecology, and health-related NGOs.

The measures announced on 29 August require private medical facilities to adopt the national standards to limit unnecessary caesarean procedures and promote safe natural delivery, based on the guidelines of the Egyptian Health Council and

the latest global standards. The measures include requiring private hospitals to submit detailed monthly reports on

Caesarean section rates classified according to the Robson system, which documents every birth and identifies whether the

caesarean was medically necessary. They also require the mandatory use of the partogram to monitor labour progression,

and electronic documentation for easier analysis and follow-up, with health directorates tasked with direct supervision.

These measures come in response to the continuously increasing caesarean delivery rates in Egypt, which reached 72% of all

births in the five years preceding the 2021 Egypt Family Health Survey, compared to 51% in 2014. This places Egypt among the highest countries worldwide in caesarean delivery rates.

This decree isn't the ministry's first intervention on this matter. In September 2022, the Minister of Health announced 

measures for public hospitals, later declaring that those policies reduced caesarean rates in public hospitals by 2% during

January and February 2023. Since then, no further information has been released regarding the outcomes of that decision.

EIPR cautions that policies focusing solely on reducing caesarean rates as an independent target may produce harmful unintended consequences. Such approaches may encourage doctors to circumvent the rules, or leave women subjected

to medical interventions against their will, and possibly against their best interests. Previous experiences with policies

driven by isolated numerical targets demonstrate such risks. For example, Egypt's anti-FGM strategy, which focused on FGM by non-medical staff has led to the current high medicalisation rates . Similarly, the government's narrow focus on

reducing maternal mortality as an isolated indicator inadvertently contributed to increased caesarean rates.

Therefore, the rise in caesarean deliveries must be viewed as a symptom of a broader issue relating to the quality of maternal healthcare services. This includes access to proper medical follow-up throughout pregnancy, accurate information, and respect of women’s dignity at every stage of care, especially during natural childbirth.

EIPR proposes that the Ministry of Health adopt a comprehensive plan to improve pregnancy and childbirth services in Egypt, covering the public and private sectors, in cooperation with specialists and civil society

organisations such as professional associations, medical schools, and patients' rights groups, particularly those focusing

on women. Such  plan should not only aim to reduce unnecessary caesarean deliveries, but also to improve the quality and

desirability of natural childbirth, ensuring women's dignity, privacy, and protection from violence, while

providing accurate information from the beginning of pregnancy follow-up. Specifically, we recommend that the plan include:

- Full adherence to WHO recommendations regarding interventions to address unnecessary caesarean deliveries, particularly

the principle that "by all possible means, caesarean deliveries must be made available to women who need them, rather than

pursuing a specific rate."

- Strict compliance with the General Comment on Article 12 (Women and Health) of the Committee on the Elimination of

Discrimination against Women (CEDAW) is a binding treaty on Egypt.

- Draw on the 2019 report of the UN Special Rapporteur on violence against women and girls regarding a

human-rights-based approach to mistreatment and violence against women in reproductive healthcare, with a focus on childbirth-related violence. Also drawing on the annual OHCHR report on technical guidance for applying a rights-based approach to policies addressing preventable maternal mortality and morbidity, which situates caesarean deliveries within a broader framework of risks to pregnant women's health and lives. Additionally, the WHO standards on improving maternal and newborn care quality in health facilities should be integrated.

- Public education, particularly for pregnant women, on the realities of both natural and caesarean deliveries, ensuring that information addresses the questions affecting women's decisions. This education should empower with knowledge and informed consent, rather than steering towards a predetermined choice.

- Improvement of natural childbirth services, guaranteeing women's rights, dignity, privacy, and access to pain relief

options where desired. Without such improvements, reducing unnecessary caesarean rates will remain limited, especially

in the private healthcare sector.

- Application of WHO recommendations regarding non-clinical interventions to reduce unnecessary caesareans, including hospital procedures, second opinions for caesarean cases, childbirth support services, and other lessons learned.

- Increased public health spending, at least meeting the constitutional minimum. Without sufficient funding for services and providers, improvement cannot be achieved. This is particularly crucial given that childbirth is one of the most common services for which families turn to the private sector, where caesarean delivery rates are significantly higher (80% in the private sector vs 63% in the public sector according to the 2021 Family Health Survey). In the most recent state budget, government health spending per person was less than 1,900 EGP annually. In comparison, debt interest payments

exceeded 17,000 EGP per person.

- Setting clear targets and indicators, requiring the Ministry of Health to publish regular data on natural and caesarean delivery rates in every health facility, along with geographical distribution, to provide meaningful inputs for policy interventions. The plan should also include periodic publication of real public spending figures on maternal and childbirth care services.