Cesarean Section Deliveries in One Health Insurance
Hospital in Alexandria
Labib NY*, Mortada MM*, Guirguis WW* *, Abd El Aziz HM*
* Family Health Department ,
* * Department of Health Administration and Behavioral Sciences, High Institute of Public Health,
Cesarean section (CS) rates have been increasing world wide, raising the question of
the appropriateness of the selection of cases for the procedure. The World Health
Organization (WHO) states that no region in the world is justified in having a cesarean
rate greater than 10 to 15 percent. The aim of the work was to determine the trend of
cesarean section deliveries in Gamal Abdel Naser Hospital which is affiliated to the
Health Insurance Organization (HIO). The study was conducted through a descriptive
retrospective approach. The study sample included the a)recorded deliveries between 1998-
2005 (n=15917) for estimating the trend of cesarean section deliveries, and b) the medical
records of CS deliveries at 2002 in the hospital (n=837) for identifying the indications of CS and
their adequacy as a source of information for evaluation of CS deliveries .The study revealed
that; cesarean section rate was high and increasing during the period from 1998 – 2005.The
highest percent was in the year 2004 (57.9%). The trend of increase was significant (χ for linear
trend = 162.717, p= 0.000).Thursdays accounted for the highest percent of both admissions and
deliveries, while Fridays accounted for the lowest percent . More than one half of deliveries
occurred between 2 pm to before 8 pm. More than three quarters of the study sample (77.9%)
did not have trial labour. Only 12.8% of the total study sample had induction and the outcome
of induction was dystocia in 85%.The main indication of cesarean section was previous CS
(41.2%), fetal distress (17.6%), failed trial and failure to progress (11.4%), cephalo-pelvic
disproportion (10.3%), abnormal presentation (5.6%) and ante-partum hemorrhage (3.2%).
Patient's records lack most of the essential information so it was not possible to verify recorded
indication to justify caesarean section.
Key Word: Cesarean Section, Deliveries, Trial labour, Induction, Indication.
Every year there are an estimated 200 million pregnancies in the world. Each
one of these faces the chance of an adverse outcome for the mother and for the baby.
While risks cannot be totally eliminated once pregnancy has begun, they can be
reduced through effective, affordable, accessible and acceptable maternity care.(1) The
WHO has estimated that almost 10% - 15% of all women develop complications
serious enough to require rapid and skilled intervention including cesarean section
(SC) if they are to survive without lifelong disabilities. (2, 3)
A cesarean delivery is performed for many indications, some indications are for
maternal benefit alone , these include: gestational diabetes, pre-eclampsia, failure to
progress in labor, failed induction and dystocia.(4-7) Some are for fetal benefit alone,
these include: malpresentation, cord prolaps, fetal distress and large sized baby.
Some are for both maternal and fetal benefits, These include; abnormal placentation,
cephalopelvic disproportion, and those situations in which pregnancy was
No consensus exists about optimal CS birth rates. WHO recommended
guidelines stating that CS birth rates should range between 5 and 15 percent,
adding that rates lower than five percent reflect women's lack of access to
life-saving care and levels more than 15 percent carry no additional benefits to
mother or new-born. (10) According to the World Health Report 2005 CS rates are
increasing throughout the world (11) raising the question of the appropriateness of the
selection of cases for the procedure.(12) In spite of being a life-saving intervention in
cases of obstructed labor or other indications, it carries risks and can lead to
morbidity of its own. It also leads to what are often major and at times
catastrophic expenditures for clients. Yet, in some countries the number of women
delivering by CS is increasing beyond all reasons. (11) Furthermore, unnecessary
caesarean sections may divert scarce resources in situations where many people
cannot get the CS they need for a life-threatening condition. (11,13) Countries with
some of the lowest perinatal mortality rates in the world have cesarean rates under
The trend of increasing the CS rate is based on the improvement of skill and
safety of the operation, broadened and not well defined indications, some
demographic, anthropological, socioeconomic, clinical, and health services factors.
(15,16) The 2005 Egypt Demographic Health Survey (EDHS) obtained information on
the frequency of cesarean section. It shows that one-fifth of the deliveries in the five
years preceding the survey was CS. (17) In Gamal Abdel Naser Hospital, the largest
Health Insurance Hospital in Alexandria, the CS rate was 47.6 % in 2000. This
exceptionally high rate warrants investigation of its indications and determinants, as
basic knowledge to plan for reducing unnecessary CS with its risk and
complications. So, the present study was conducted with the aim of revealing the
trend of CS, identifying the reported indications, and investigating adequacy of
medical records as a source of information for monitoring and evaluation of CS
deliveries in Gamal Abed El Naser Health Insurance Hospital in Alexandria.
MATERIAL AND METHODS
The study was conducted through a descriptive retrospective approach. It was
carried out at Gamal Abdel Naser Hospital. This hospital is composed of 1001 beds,
of which 52 are allocated to the Obstetrics & Gynecology Department. All deliveries
recorded in the hospital from 1998 to 2005 constituted the study sample for
estimating the trend of CS deliveries. They summed up to 15917. All records of CS
deliveries conducted in the year 2002 were reviewed via a compilation sheet for
identifying the indications and determining their adequacy as a source of
information for monitoring and evaluation of CS deliveries. They summed up to 837.
Statistical analysis was conducted using PC with the software SPSS version 13.0.
Mann-whitney test count and percentage was used for comparing two independent
quantitative non-normally distributed variables. Chi Square for linear trend was used to
compare differences throughout the studied years. The level of significance selected was the
There is a significant trend of increase in CS deliveries (χ for linear trend =
162.717, p= 0.000). It ranged from 33.7% in the year 1999 to 57.9% in the year 2004
(Figure 1). Primary CS constituted more than 50% of all CS deliveries in all years
from 1998 – 2005. The highest percent of primary CS was in the year 2000 (59.3%).
Regarding the repeat CS, the highest percent was in the year 2005 (47.7%), while the
lowest percent was in the year 2000 (40.7%, Figure 2).
During the year 2002 the highest percent of CS (31.7%) was at the age 30 to < 35
years and the mean age was 32.47 ± 5.33 years. Nullipara and primipara constituted
more than one third of deliveries (37.5% and 36.0%). Only 15.3% had experienced
one abortion. Women with history of two or more still births constituted minimal
percent (0.6%). This fifths of the sample (40.0%) had no previous live births. More
than one third (36.1%) had only one live birth. More than half of the sample (56.2%,
58.8%) had no history of previous abnormal deliveries or CS, while about one third
of them had history of one previous CS (30.0%, Table 1).
P e rc e n t
1998 1999 2000 2001 2002 2003 2004 2005 2006
Figure (1): Cesarean Section Rate in Gamal Abdel Naser Hospital During the Period
Prim ary CS Repeat CS
45.7 43.3 40.7 41.6 41.2
80 43.6 45.2 47.7
1998 1999 2000 2001 2002 2003 2004 2005
Figure (2): Distribution of CS Deliveries at Gamal Abdel Naser Hospital During the
Period from 1998-2005 According to the Frequency of Section
Table (1): Distribution of CS Deliveries at Gamal Abdel Naser Hospital During the
Year 2002 by Age and Some Reproductive Characteristics
Age in years No. %
Below 20 years 2 0.2
20 - 54 6.5
25- 208 24.8
30- 265 31.7
35- 224 26.8
40 or more 84 10.0
Mean ± SD = 32.47 ± 5.33
Nullipara 314 37.5
Primipara 301 36.0
Para 2, para 3 202 24.1
Para 4 or more 20 2.4
No previous abortions 623 74.4
One 128 15.4
Two 48 5.7
Three or more 38 4.5
Previous still births
No previous still birth 792 94.6
One 40 4.8
Two or three 5 0.6
Number of live births
No previous live births 335 40.0
One 302 36.1
Two 137 16.4
Three or more 63 7.5
Previous abnormal deliveries#
No previous abnormal deliveries 470 56.2
C.S. 345 41.2
Ventose 91 10.9
Forceps 23 2.7
Bilateral cervical tear 3 0.4
0 492 58.8
1 252 30.1
2 75 9.0
3 17 2.0
4 1 0.1
More than one answer allowed
Pelvic examination was not done for 22.6% of the sample. In about one third of
the sample, the cervix was closed (33.0 %). The interval between admission and
delivery ranged from 2 - <4 hours in about one third of the sample (32.0%).
Table (2): Distribution of CS Deliveries at Gamal Abdel Naser Hospital During the
year 2002 by Day of Admission, Day and hour of Delivery.
Day of admission
Saturday 129 15.4
Sunday 121 14.5
Monday 118 14.1
Tuesday 125 14.8
Wednesday 111 13.3
Thursday 163 19.5
Friday 70 8.4
Day of delivery
Saturday 119 14.2
Sunday 116 13.9
Monday 116 13.9
Tuesday 124 14.8
Wednesday 108 12.8
Thursday 174 20.8
Friday 80 9.6
Hour of delivery
8 am to before 2 pm 82 9.8
2 pm to before 8 pm 447 53.4
8 pm to before 8 am 308 36.8
Thursdays accounted for the highest percent of both admissions and deliveries
(19.5% and 20.8%, respectively). On the other hand, Fridays accounted for the lowest
percent of both admissions and deliveries (8.4% and 9.6% respectively). More than
one half of deliveries occurred between 2 pm to before 8 pm (53.4%), while about one
third of deliveries occurred between 8 pm to before 8 am (36.8 %, Table 2).
Table (3): Distribution of CS Deliveries at Gamal Abdel Naser Hospital During the
Year 2002 by Prior Trial Labor and their Main Reported Indication.
Variables No. %
CS without trial labour (Elective) 652 77.9
CS after trial labour 185 22.1
Previous CS 345 41.2
Previous one CS 252 73.0
With tender scar 211 61.2
With no tender scar 41 11.9
- Other indication 32 9.3
- No other indication 9 2.6
More than one CS 93 27.0
Foetal distress 147 17.6
Failed trial / Failure to progress 95 11.4
Cephalo-pelvic disproportion 86 10.3
Abnormal presentation 47 5.6
Antipartum Haemorrhage 27 3.2
Primary and secondary infertility 21 2.5
Decreased liquor / Premature rupture of membranes 19 2.3
Eclampsia 12 1.4
Twins 9 1.0
Others 29 3.0
Total 837 100.0
More than three quarters of the study sample (77.9%) did not have trial labor,
i.e., elective CS. Cesarean section after spontaneous labor constituted 9.3%, while CS
after induced labor constituted 7.3%. Regarding the main indication of cesarean
section, previous cesarean section constituted more than one third of the cases
(41.2%). Out of them nearly three quarters (73%) were previous one CS. Fetal
distress, failed trial and failure to progress and cephalo-pelvic disproportion
constituted the main indications for 17.6%, 11.4% and 10.3% of the sample
respectively, while abnormal presentation and ante-partum hemorrhage
represented 5.6% and 3.2% respectively (Table 3).
Table (4): Association Between Induction of Delivery and the Interval Between
Admission and CS Delivery at Gamal Abdel Naser Hospital During the
Interval between Induction Total
admission and No Yes
delivery No. % No. % No. %
< 2 hours 176 96.7 6 3.3 182 100.0
2- 255 95.1 13 4.9 268 100.0
4- 142 87.7 20 12.3 162 100.0
6- 61 77.2 18 22.8 79 100.0
12 - 50 61.7 31 38.3 81 100.0
24 hours or more 46 70.8 19 29.2 65 100.0
Mean ± SD 9.617 ± 30.53 14.04 ± 14.02 10.18 ± 28.98
(Median) (3.43) (10.22) (3.72)
Total 730 87.2 107 12.8 837 100.0
Test of significance Mann-Whitney U= 8.78 p= 0.000
Table (5): Distribution of CS Deliveries After Induction of Labour at Gamal Abdel
Naser Hospital During the Year 2002 by the Outcome of Induction.
Outcome of induction No. %
Dystocia 91 85.1
Non engaged head / Cephalo-pelvic disproportion 8 7.5
Foetal distress 7 6.5
Ante-partum haemorrhage 1 0.9
Total 107 100.0
Only 12.8% of the total study sample had induction. There is significant increase
in the percent of cases those underwent induction as the interval between admission
and delivery increased. The outcome of induction were dystocia in 85%, non
engaged head and cephalopelvic-disproportion in 7.5%, fetal distress and ante-
partum hemorrhage in 6.5%, and 0.9% respectively (Tables 4, 5).
Regarding data denoting adequacy of medical records as a monitor to justify CS
rate, table 6 shows that partogram, regular fetal heart sound follow up (recorded
every 30 minutes), cardiotocography and time of starting induction were not recorded
for the entire study sample (0.0%)
Table (6): Distribution of CS Deliveries at Gamal Abdel Naser Hospital During the
Year 2002 According to the Denoting Data Regarding Adequacy of Medical
Records as a Monitor to Justify CS Rate.
Recorded Not recorded Total
No. % No. % No. %
Partogram 0 0.0 837 100.0 837 100.0
Foetal monitor 1 0.1 836 99.9 837 100.0
Foetal heart sound once or twice (FHS) 754 90.1 83 9.9 837 100.0
Regular foetal heart sound follow up recorded 0 0.0 837 100.0 837 100.0
every 30 minutes
Induction (n= 107)
Time of starting 0/107 0.0 107/107 100.0 107 100.0
Syntocinon 107/107 100.0 0/107 0.0 107 100.0
vagiprost 5/107 4.7 102/107 95.3 107 100.0
Ultrasound 816 97.5 21 2.5 837 100.0
Doppler Ultrasound 8 1.0 829 99.0 837 100.0
Cardiotocography (CTG) 0 0.0 837 100.0 837 100.0
Non-stress test (Outside hospital) 2 0.2 835 99.8 837 100.0
Cesarean section has been one of the most important operations in obstetrics
and gynecology as of its lifesaving value to both mother and fetus. (18) The World
Bank review of service delivery models in selected developing countries revealed
that a hospital with comprehensive essential obstetric care should be available and
able to provide CS deliveries and blood transfusions in order to reduce the maternal
mortality rate. (19) So, within the specialized hospital or tertiary care model, birth is
treated as a medical problem. This has led to huge amounts of unnecessary and
costly medical interventions. (20) Cesarean section remains an important area of
controversy because of increase in the rate of this operation worldwide. Breech
presentation, prematurity, increased use of electronic fetal monitoring, and fear of
litigation has been implicated, and obstetricians have been largely blamed for the
rising trend of CS deliveries. (21)
The present study revealed that CS rates in Gamal Abed El Naser hospital for
the years 1998 to 2005 were very high and the trend of increase was significant (χ2 for
linear trend = 162.717, p = 0.000), the maximum rate was 57.9% in the year 2004. (Fig.
1) This trend coincides with that of other researches in Egypt.(17, 22) However, these
figures were much higher than those reported by these researches. These high CS
rates in the present study may be attributed to the study being a hospital-based and
not a community-based one. Furthermore, Gamal Abdel Naser hospital serves
working women who are more educated and more exposed to stress. Advancing
maternal age may also explain this increase as the highest percent of CS was in the
age group 30 – 40 years, also low parity as nearly three quarters of the sample were
either nullipara or primipara (73.5%, Table 1). In addition, CS rates vary widely all
over the world, but upward increase in the present study is in accordance with a
vast body of researches. (18, 24 - 29)
The highest percent of admissions and deliveries in the present study occurred
on Thursday, while the lowest percent of admission and deliveries occurred on
Friday (Table 2) to minimize the work at the week end. This result was in
concordance with the Brazil study.(15,16) Also the highest percent of CS occurred
between 2 pm and 8 pm, while the lowest percent occurred between 8 am to 2 am
(Table 2). This was preferred by the obstetrician to make deliveries in late afternoon
and evening, at the end of office hours–the period with minimal supervision relative
to the morning period. Also, because it allows them “to work a minimum of non-
social hours”. This suggests that non clinical factors play a major role in the decision
to perform a CS. (17) This result was in concordance with several studies. (15, 16, 23- 25)
Financial incentives also resulted in higher cesarean rates, where physicians are paid
twice as much for CS as for a vaginal delivery. Even government provision can be
skewed by the greater financial reimbursement given for these than for normal
vaginal deliveries.(26, 30) These financial incentives might explain high CS rate in the
On the other hand, CS rate was low in some developing countries as in Jordan.
A study done in 7 major military hospitals recorded a 3.9% increase in the rate of CS
from 1990 to 2001 (from 7.6-11.5 per hundred deliveries). (18) This increase compared
with increase in the rate in the USA and in many European countries is very small.
The explanation of why Jordanian cesarean rate is still low despite the increase
internationally was that the same policy is used in most hospitals in Jordan, which is
trial of labor for fetuses weight > 4000 gm, the use of oxytocin in higher doses and for
longer duration and importantly the decrease in performing the procedure for
fetuses gestational age <30 weeks. This policy is due to the absence of highly
qualified neonatology units, as well as supervision and performance of deliveries by
midwives in more than 85% of deliveries, also, the absence of medico-legal pressure.
The present study also revealed that primary CS constituted more than 50 % of
all CS deliveries from 1998 to 2005. The high primary CS rate might be due to short
interval between admission and delivery for most cases, not allowing enough time
for induction (table 4). There was no follow up by fetal monitor or partogram (table
6). Cesarean section was conducted while pelvic examination on admission was not
done for 22.6%, the cervix was closed in 33.0% and was one finger in 25.8%. This
means that they were admitted for elective CS or did not take trial of labor.
Cesarean section deliveries after previous one CS constituted the highest percent
(73.0%) of all repeat CS, also they didn't take chance for vaginal birth after cesarean
(VBAC). This might indicate that operative deliveries were done for cases with
previous one CS on an elective basis without any trial of VBAC and this was in
accordance with many studies. (31, 32) Despite the US healthy people 2010 objective of a
VBAC recommended rate of 37 %,(33 ) cesarean delivery rate reached 27.6% in 2003;
more than one third of these were repeat CS. Also, the rate of VBAC fell from 31% in
1998 to 10.6% in 2003. (34) This could be justifying the high cesarean delivery rate all
over the world.
The present study was based on a retrospective record review. One of the study
objectives was to assess the adequacy of information recorded in the patient's record to
verify the indications recorded by the physician and to judge the justification of the
indication. Results revealed that the patient's record lacked most of the essential
information (table 6); partogram, fetal monitor, regular fetal heart sound follow up
recorded every 30 minutes and cardiotocography. Accordingly, it is not possible to
verify recorded indication or justify CS. Examination of the indication recorded in
the patient's record revealed that the main indication for CS among study cases was
previous CS (table 3).
In agreement with the present study, in Thailand in the year 2000, a study
showed that repeat CS was the most common indication in the private hospitals
(63%), and university hospital (88%) while failure to progress was the most common
indication in general hospitals (55%). (35) On the contrary, in Jordan the most common
indications were failure to progress (18.8%) while, previous CS was (13.3%). (36)
These findings may be attributed to the possibility that physicians might still be
following the rule of “once cesarean always cesarean”. It was also found that in most
of cases with previous one CS ‘tender scar’ was reported as an indication in the
medical record denoting either previous bad surgical technique or may be a trial to
justify the operation (Table 3) and even though they didn’t take a trial of labour.
Countries in Europe achieve more than 50% of vaginal births after a prior CS
compared with 25% in the USA but in Jordan it was achieved in more than 75%.(37 )
Fetal distress constituted the second common reported indication in the present
study (17.6%), although there was no documentation in the files to prove that (table
6). Absence of evidence might be due to non use of fetal monitor or external
cardiotocography for diagnosis of fetal distress. The diagnosis most probably
depends only on fetal heart sound for follow up of cases. Fetal distress also
contributed to an increase CS rate significantly in Jordan. The diagnosis of fetal
distress was based on the abnormal cardiotocographic (CTG) findings and the
proved severe fetal bradycardia by intermittent auscultation. (18) Several studies
showed that Doppler auscultation of the fetal heart, admission of cardiotocography
doesn’t benefit neonatal outcome in low risk women but its use results in increased
obstetric intervention, including operative delivery. (18, 38)
In the present study the third common indication was failed trial and failure to
progress (11.4%), then cephalo-pelvic disproportion (10.3%, Table 3). Regarding the
cases diagnosed as failed trial and failure to progress (dystocia), there is no
documentation in patient's records for the dose of oxytocin or the progress of labor
such as partogram (table 6). The recorded causes of failure of induction were
dystocia which is the main outcome (85.1%), cephalopelvic disproportion (7.5%)
and fetal distress (6.5%, Table 5). Dystocia constituted the highest percent, which
might be due to use of inappropriate oxytocin dosage, improper follow up in the first
stage of labor, or non use of partogram. So the term dystocia might be over used as
an indication to justify the performance of CS. This was in concordance with another
study (18) where, significant decrease in the percentage of CS which was performed
for dystocia was reported due to more accuracy in estimation of the fetal body
weight, and with proper use of oxytocin dosage which can correct malrotation of
vertex leading to subsequent reduction in CS rate for dystocia.
In the present study breech presentation was the main abnormal fetal
presentation. Breech presentation at term is seen in approximately 3%-4% of
pregnancies. In 1959, Wright recommended cesarean delivery for the fetus with a
breech presentation. This recommendation, along with others, led to a major change
in the management of breech presentation. (37) Breech presentation was the third
most important cause of the rise in cesarean delivery rate during the past 20 years.
The performance of cesarean delivery for breech presentation not only increases the
primary cesarean delivery rate but also has an impact on the total cesarean delivery
rate for the future because many women may have repeated cesarean deliveries in
subsequent pregnancies. (37)
The general practice is still to deliver most breeches by CS regardless of the
estimated fetal weight.(18) There is evidence that external cephalic version can
substantially change the incidence of breech presentation at delivery precluding the
need for cesarean section. So it is an effective and safe procedure and should be
included in the routine management of breech presentation.(37 ) The reported success
rate of term external cephalic version ranges from 41% to 77% with a very low
reversion rate.(37, 39)
In light of the present findings, the following recommendations to reduce CS
rate are suggested:
1. Every hospital that has an obstetric service should have some committee that
examines every CS is performed in that hospital and determines whether it was
indicated or not. If it was not indicated, then the physician who performed the
section should be educated as to why it was not indicated.
2. Regular monitoring of CS rate in Gamal Abdel Naser Hospital including
indication and feed back to different units and individual physicians.
3. Raising the awareness of the physician about:
• The importance of attempting vaginal delivery for patient who meets criteria for
attempt vaginal delivery.
• The appropriate indications of CS.
• Decrease CS for breech presentation (along with more cephalic versions)
4. Active encouragement of vaginal birth after cesarean (VBAC).
5. An medical record form should be designed to record the CS deliveries including
the indication as well as data to verify this indication. Completion of this form
should be regularly monitored.
1. WHO. Every pregnancy faces risk. World Health Day Safe Motherhood.7th April
2. Abou Zaher C, Murray C, Lopez A. Maternal mortality: overview. In: The health
dimensions of sex and reproduction. Boston: Harverd University; 1998: p.147.
3. Johanson R., Newburn M., Macfarlane A. Has the medicalization of childbirth gone
too far?. BMJ. 2002; 24:892-5.
4. Langer A, Villar J. promoting evidence based practice in maternal care. BMJ. 2002;
5. Wagner M. Choosing cesarean section. Lancet. 2000; 356 (11): 1677- 80
6. Aisien A, Lawson J, Adebayo A. A five year appraisal of cesarean section in a northen
Nigeria university teaching hospital. Niger Postgrad Med J. 2002; 9(3): 146-50.
7. Asenova D, Stambolov B. Incidence and indications for cesarean section in the
obstetrics clinic in the university hospital of obstetrics and gynecology “ Maichin Dom
“ in Sofia. Akush Ginekol. 2005; 3: 15-7.
8. Sehdev H, Pritzker J, Talavera F, Legro R, Gaupp F, Shulman L. Cesarean delivery. E
medicine. 2005 [Cited 2005Aug 25]. Available from: http:// www.
9. Sims C, Meyn L, Caruana R, Rao R, Mitchell T, krohn M. Predicting cesarean delivery
with decision tree models. Am J Obstet Gynaecol. 2000; 183(5) : 1-12.
10. WHO. Indicators to monitor maternal health goals. Report of a technical working
group, 8-12 November 1993. Geneva, WHO; 1994.
11. WHO. Newborn no longer going unnoticed. In: World Health Report: 2005, Make
every mother and child count. Geneva: WHO. p. 94- 101
12. Mishra US, ramanathan M. Delivery- related complications and determinants of
cesarean section rates in India. Health Policy and Planning. 2002; 17(1):90-8.
13. Fathalla MF. A women friendly health care system. In: Issues in women's health: international
and Egyptian perspectives. Assiut University 2006; p.19-22.
14. National Center for Health Statistics. Child Health. USA: 2004.
15. Gomes U, Silva A, Bettiol H, Barbieri M. Risk factors for increasing cesarean section
rate in southeast Brazil. International Journal of Epidemiology. 1999; 28: 687-94.
16. Gomes UA. High cesarean section rates in Brazil result in large part from non clinical
factors. Family Planning Perspectives. 2000;26(1): 1-2.
17. El-Zanaty F, Way AA. Egypt Demographic and Health Survey 2005. Ministry of Health
and Population (Egypt): National Population Council, El Zanaty and Associates, and
ORC Macro, 2006: p129.
18. Ibrahim M, Hindawi M, Zakarya H. The Jordanian cesarean section rate. Saudi Med J.
2004;25 (11): 1631- 5.
19. World Bank. Reducing maternal mortality: learning from Bolivia, China, Egypt, Honduras,
indonsia, Jamaica, and Zimbabwe. World Bank. 2003: p. 6-37.
20. Wagner M. General situation of obstetrics in the world : how the scientific medical
power help to perpetuate the concept: they shall deliver with fear. First International
Congress on Home Delivery and Child birth, Spain, October 2000.
21. Kimberly D, Lisa M, Lawrence D. Variations in elective primary cesarean delivery by
patient and hospital factors. Am J Obestet Gynecol. 2001;184(7): 1-2.
22. Khawaja M, Jurdi R, Kabakian T. Rising trends in cesarean section rates in Egypt. Birth.
23. Hopkins K. Are Brazilian women really choosing to deliver by cesarean? Social Science
and Medicine. 2000; 51(5):725-40.
24. Leung GM. Rates of cesarean births in Hong Kong: 1987-1999. Birth. 2001; 28 (3): 166-
25. Aali B, Motamedi B. Women’s knowledge and attitude towards modes of delivery in
Kerman, Islamic Republic of Iran. Eastern Mediterranean Health Journal. 2005; 11 (4):
26. Gonzalez G, Vega M, Cabrera C, Munoz A, Valle A. Cesarean sections in Mexico: are
there too many? Health Policy Plan. 2001; 16 (1) :62 -7.
27. Sheppard J, Tumarkin L, Hartwell E, Nowicki E. A mother's right to know: New York
City Hospitals fail to provide legally mandated maternity information. A Report by
Public Advocated Betsy Got Baum 2005 [Cited 2006 Oct 10]. Available from: www.
28. Winter R, Hepp H, Haller U. Does the increasing cesarean section rate reflect a shift in
indications or a decline in quality?. Gynakol Geburtshilfliche Rundsch. 2000; 40(3-4) :
117 – 8.
29. Stanton CK, Holtz S. Levels and trends in caesarean birth in the developing world.
Studies in Family Planning. 2006. 37:41- 8.
30. Mirsky J. Birth rights: the medicalization of childbirth Gaoy NUD, editor. Dakar,
Kampala, London, Lusaka, Paris, Washington: The PANOS Institute. Panos Reports No
43, 2001: p. 30-43.
31. Burke J. Dostol J, Deitrick L, Kimmel S. The increasing rate of repeat cesarean section at
a community FM residency program. Family Medicine. 2005; 37 (7): 459- 60.
32. Al-Nuaim L. Views of women towards cesarean section. Saudi Med J. 2004; 25 (6):707-
33. Public Health Service. Healthy People 2010. Washington, DC: US. Department of
Health and Human Services, 2000.
34. Hamilton B, M artin J, Sutton P. Births: preliminary data for 2003. Natal Vital Stat Rep.
35. Chanrachakul B, Herabutya Y, Udomsubpayakul U. Epidemic of cesarean section at
the general, private and university hospitals in Thailand. J Obestet Gynaecol. 2000; 26
(5) : 357 – 61.
36. Akasheh HF, Amarin V. Cesarean section at queen Alia Military Hospital, Jordan: a six
year review. Eastern Mediterranean Health Journal. 2000; 6 (1 ): 41-5.
37. Wright RC. Reduction of perinatal mortality and morbidity in breech delivery through
routine use of cesarean section. Obstetrics and Gynecology. 1959; 14: 758-63. Cited by:
Hindawi I. Value and pregnancy outcome of external cephalic version. Eastern
Mediterranean Health Journal 2005; 11 (4): 633- 9.
38. Mires G, Williams F, Howie P. Randomised controlled trial of cardiotocography versus
Doppler auscultation of fetal heart at admission in labor in low risk obstetric
population. BMJ. 2001; 322 (7300): 1457- 60.
39. Regalia AL. Routine use of external cephalic version in three hospitals. Birth. 2000;