doi: 10.1093/heapol/czh012
HEALTH POLICY AND PLANNING; 19(2): 101–110
Health Policy and Planning 19(2),
© Oxford University Press, 2004; all rights reserved.
Caesarean section rates in the Arab region:
a cross-national study
ROZZET JURDI AND MARWAN KHAWAJA
Centre for Research on Population and Health, Faculty of Health Sciences, American University of Beirut, Beirut,
Lebanon
This study had a dual purpose of estimating population- and hospital-based caesarean section rates in 18
Arab countries and examining the association between these rates and important indicators of socioeconomic development. Data on caesarean section were based on the most recent population-based surveys
undertaken in each country. Descriptive statistics and bivariate correlation coefficients were used for the
analysis. Specifically, Spearman’s rank correlation coefficients were used to analyze the associations
between caesarean section rates and important population parameters. Results revealed that four Arab countries had population-based caesarean rates below 5%, while only three countries had rates above 15%. The
remaining 11 countries had caesarean rates ranging between 5–15%. Higher hospital-based rates were
reported for all countries. Differences in caesarean section rates between private and public hospitals were
also noted. Highly significant associations were observed between population caesarean rates and female
literacy, percentage urban, infant mortality rate, and the proportion of physicians per 100 000 people. The
‘caesarean section epidemic’ observed in countries of Latin America is not yet evident in the 18 Arab countries examined. Rather, emphasis should be on improving access to appropriate obstetrical interventions in
case of complications in a number of countries where rates were well below 5%.
Key words: caesarean section, socioeconomic development, health system, Arab countries
Introduction
The number of women having babies born by caesarean
section is growing rapidly in both developed and developing
countries (The Lancet 2000; Dosa 2001). Concern has been
expressed at these growing rates (De Muylder 1993).
Although safer caesarean section delivery may reduce
maternal and infant morbidity and mortality, it remains a
major surgical procedure with serious implications for the
health of mother and child. Caesarean section deliveries
carry high health risks including respiratory complications
and neurological impairment of the newborn and long-term
postpartum morbidity for the mother (Russell 1981; De
Muylder 1993; Glazener et al. 1995; Belizan et al. 1999).
Furthermore, caesarean deliveries require the use of more
medical and healthcare resources compared with normal
deliveries, becoming as such a real burden to health systems
working with limited budgets (De Muylder 1993; Glazener et
al. 1995; Belizan et al. 1999). An increasing number of studies
have been conducted on this topic, particularly in countries
undergoing rapid demographic and health transitions such as
South American countries, where the incidence of caesarean
section is very high even compared with rates in developed
societies (Belizan et al. 1999; Savage 2000).
Little is known about the prevalence of caesarean deliveries
in the Arab world, a region that has been undergoing salient
demographic changes. There has been some available
evidence for a few of the countries in this region, and even
for these countries, studies are largely based on hospitalbased samples (Chattopadhyay et al. 1987; Guirguis and AlSaleh 1991; Elhag et al. 1994; Hughes and Morrison 1994;
Ziadeh and Abu-Heija 1995; Abu-Heija and Zayed 1998;
Abu-Heija et al. 1999; Akasheh and Amarin 2000; Khayat
and Campbell 2000; Mesleh et al. 2000; Ziadeh et al. 2000;
Mesleh et al. 2001). This is surprising given the availability of
national-level micro-data from the Pan Arab Project for
Child Development (PAPCHILD) and the Demographic
Health Survey (DHS) programmes for several countries in
the region.
At the turn of the 21st century, the Arab region is entering
an era of dramatic demographic shifts with obvious health
consequences. Declining fertility, now underway in most
countries, is one of the most significant phenomena in the
region today. The fertility decline is likely to result in
improved maternal and child health (Cook 1987) as well as a
substantially changed age structure and distribution, with
gradually fewer dependants. As countries move through the
demographic transition, important questions arise about the
effect of this phenomenon on maternal health, the well-being
of families and other issues of policy concern. Yet, the demographic changes currently underway in the region are far
from uniform. As a result of the demographic transition, the
demographic and socioeconomic gaps between different
countries and areas within countries seem wider than ever
(UNDP and AFESD 2002). Furthermore, a quick look at the
onset of demographic and health transitions reveals little
correspondence with socioeconomic development in this
context. The presence of oil-rich countries and prolonged
political conflict and wars contribute to these demographic
and health anomalies (Omran and Roudi 1993).
This study has a dual purpose of (1) estimating the
102
Rozzet Jurdi and Marwan Khawaja
prevalence of caesarean section in 18 Arab countries and (2)
correlating these with important demographic, socioeconomic and health characteristics of the populations under
study. Cook (1987) argued that maternal health and obstetric care should improve in this region with increased urbanization, education and literacy. Establishing the prevalence
and correlates of caesarean delivery in this region is of
considerable policy concern. According to UNICEF et al.
(1997), rates of caesarean section below 5% seem to be
associated with gaps in obstetric care leading as such to poor
health outcomes for mother and child, whereas rates over
15% do not seem to improve either maternal or infant health.
Is there a need to increase or reduce the caesarean delivery
rates towards the ‘acceptable’ range in the countries under
examination? What is the potential impact of demographic
transition and/or socioeconomic development on rates of
caesarean section delivery in this region?
Data and methods
Given the purpose of our study, we sought (1) information
about the prevalence of caesarean section, as well as (2) data
on the structural context (demographic and socioeconomic
environment) of countries in which caesarean section took
place. In both cases, we relied on secondary, or otherwise
published, sources. To obtain latest data for each country
included in the study, we contacted the DHS program, Population Research Unit of the Arab League, and Palestinian
Central Bureau of Statistics.
Our main sources of data on caesarean section were the most
recent population-based surveys undertaken in each of the 18
Arab countries under examination. Here, we relied on
various data sources. First, micro-data from the DHS program
were used for Egypt (EDHS 2000), Yemen (YDHS 1997) and
Mauritania (ORC Macro 2003). For Jordan (JDHS 1997), we
used data from the published report. Second, the 1996 Demographic Survey in the West Bank and Gaza Strip, designed
and implemented by the Palestinian Central Bureau of Statistics, was used to calculate estimates for the Palestinian areas.
Finally, data for the remaining countries were obtained from
published reports of national surveys carried out by
PAPCHILD of the League of Arab States and UNFPA.
Published reports from the Arab Maternal and Child Health
Survey programme were used for Algeria (AMCHS 1993),
Lebanon (LMCHS 1996), Libya (ALMCHS 1995), Morocco
(MMCHS 1999), Sudan (SMCHS 1993) and Tunisia (TMCHS
1994–5), countries where national micro-data could not be
accessed. Likewise, the Gulf Family Health Survey reports
were used for information about Bahrain (BFHS 1995),
Kuwait (KFHS 1996), Oman (OFHS 1995), Qatar (QFHS
1998), Saudi Arabia (SAFHS 1996) and United Arab
Emirates (UAE) (EFHS 1995). For Syria (SARMCHS 2001),
we used information obtained from the first national survey
carried out by the Pan Arab Project for Family Health
(PAPFAM) of the League of Arab States which was originally
developed out of the PAPCHILD survey and it aims to
provide information on Arab family health.
All of these national surveys used largely standardized
instruments and similar methodologies, thus enhancing
comparability of data between countries and over time. Table
1 provides information about sample characteristics of the
surveys in question.
In all these surveys, women were asked the same questions
about their pregnancies during the past 5 years before the
survey. Specifically, mothers were asked if they had any pregnancy during the 5 years preceding the survey, and about
complications during delivery if any. Among the various
Table 1. Sources of data on caesarean section
Country
National
survey
Year
No. of
No. of
No. of
households women
births
interviewed interviewed
Response
rate (%)
Source
Algeria
AMCHS
1993
6 694
5 881
5 288
93.7
3 725
15 573
5 548
3 453
3 317
5 164
3 120
11 467
6 360
3 514
2 156
5 348
94.0
99.1
96.4
91.0
93.0
95.0
7 728
5 311
6 405
3 564
3 787
8 894
4 869
6 953
4 920
5 745
10 414
5 088
3 815
9 033
4 630
3 775
10 831
4 585
4 038
3 783
6 285
12 451
97.6
95.0
94.7
94.6
83.0
94.5
96.6
95.0
96.3
97.0
95.8
Ministry of Health and Population [Algeria]
(1994)
Naseeb and Farid (2000)
Micro data
Department of Statistics [Jordan] (1998)
Alnesef et al. (2000)
Ministry of Public Health [Lebanon] (1998)
The General People’s Committee for Health
and Social Insurance [Libya] (1996)
ORC Macro (2003)
Ministry of Health [Morocco] (2000)
Sulaiman et al. (2000)
Palestinian Central Bureau of Statistics (1997)
Al-Jaber and Farid (2000)
Khoja and Farid (2000)
Ministry of Public Health [Sudan] (1995)
Central Bureau of Statistics [Syria] (2002)
Ministry of Public Health [Tunisia] (1996)
Fikri and Farid (2000)
Micro data
Bahrain
Egypt
Jordan
Kuwait
Lebanon
Libya
BFHS
EDHS
JDHS
KFHS
LMCHS
ALMCHS
1995
2000
1997
1996
1996
1995
4 166
16 957
7 335
3 673
4 600
6 312
Mauritania
Morocco
Oman
Palestine
Qatar
Saudi Arabia
Sudan
Syria
Tunisia
UAE
Yemen
MDHS
MMCHS
OFHS
PDS
QFHS
SFHS
SMCHS
SRMCHS
TMCHS
EFHS
YDMCHS
2000–1
1999
1995
1996
1998
1996
1993
2001
1994–5
1995
1997
6 149
6 000
6 304
3 722
4 207
10 510
5 320
9 500
6 308
5 822
10 701
C-section in the Arab region
complications reported, we focused on caesarean section
deliveries.
Our sources of data for national-level demographic and
socioeconomic indicators were the UN PRED (2002) and
WHO (2002) cross-national databases for all the countries
included here except for the Palestinian areas. Data for the
Palestinian areas were obtained directly from the Palestinian
Central Bureau of Statistics (2002) in Ramallah. The UN
PRED is a machine-readable database prepared by the
Population Division of the Department of Economic and
Social Affairs of the United Nations Secretariat. This
database contains national, comparative indicators on
various aspects of population, resources, environment and
development for 228 countries or areas of the world. Population estimates and projections were produced by the Population Division of the UN. Other data were contributed
directly, or indirectly from published sources, by the various
specialized UN agencies including FAO, ILO, UNEP,
UNESCO, UNFPA, UNICEF and WHO, and the World
Bank. For consistency purposes, the WHO database, United
Nations specialized agency for health, was used to obtain
information on health personnel for countries in the region.
Estimates of health personnel were made by the World
Health Organization Regional Office for the Eastern
Mediterranean (WHO 2002). There is some variability in the
quality of the data used in these databases (UN PRED 2002;
WHO 2002). According to the UN, ‘despite the considerable
efforts of international organisations to collect, process and
disseminate social and economic statistics and to standardize
definitions and data collection methods, limitations remain in
the data coverage, consistency and comparability of data
across time and between countries’ (UN PRED 2002). To our
knowledge, the country level data provided by UN agencies
remain the best available for conducting cross-national
studies.
The indicators obtained from these two machine-readable
databases and from the Palestinian Central Bureau of Statistics were chosen based on their proximity to the year of the
survey in question. In cases where we could not obtain macro
data for the same year of the survey date, we used available
data for the year closest to the survey date. We relied on a
set of widely used development indicators, including percentage of the population that is urban, adult female literacy rate,
gross domestic product (GDP) per capita in US$ adjusted for
purchasing power parities, total fertility rate (TFR), percentage of women having institutional deliveries, proportion of
physicians per 100 000 people, infant mortality rate (IMR)
and maternal mortality ratio (MMR). Taken together, these
indicators permit a preliminary examination of the links
between caesarean section prevalence in a country and its
wider socioeconomic context. The Appendix provides a brief
summary of the data sources, variables used and their definition.
For the analysis, both population and hospital-based
caesarean section prevalence rates for Arab countries were
(if appropriate) estimated and documented. Estimation was
done for 12 countries that lacked data on population
caesarean section. We used information from published
103
survey reports on total number of deliveries, proportion of
hospital births and caesarean section rates for women with
births in the time period covered by these surveys. In
estimating the rates, we made the assumption that the
proportion of caesarean section deliveries at home is nil in
these countries, as had been the case in the countries where
this information was readily available. We divided the
number of caesarean section deliveries (given) by the total
number of births irrespective of place of delivery (given).
Belizan et al. (1999) used a similar methodology in their
study in Latin America. To increase confidence in the estimates, we compared the caesarean rates of countries for
which we had the micro-data sets with the rates obtained
from their published reports. The results were almost identical. The associations between caesarean section rates and the
demographic, socioeconomic and health indicators were
analyzed using Spearman’s rank correlation coefficients. The
analysis reported here was undertaken by the program Stata
7 for Windows (2001).
Results
Table 2 presents information on important demographic,
socioeconomic and health indicators for 18 countries in the
Arab region. Clearly, this region is quite diverse. For
convenience purposes, the countries examined were classified into four groups based on their socioeconomic profiles.
The first group included the Gulf countries and Libya,
characterized by high GDPs, high rates of urbanization,
impressively low infant and maternal mortality rates, and
high rates of institutional deliveries. Some of these countries
could be characterized demographically as pre-transitional
owing to still high fertility rates: Saudi Arabia and Oman had
an estimated TFR of 6.2 and 5.9 children, respectively. Other
Gulf countries such as Bahrain and UAE could be classified
instead as transitional countries. The second set of countries
included Lebanon and Tunisia. These were found to be upper
middle-income countries, with very low fertility rates and
infant mortality rates, high female literacy, and high institutional delivery rates. With TFR approaching replacement
levels, Lebanon and Tunisia could be considered as forerunners in the fertility transition. The third category of countries included Algeria, Egypt, Jordan, Morocco, Palestine
and Syria, lower and upper middle-income countries, characterized mostly by high urbanization, female literacy rates,
accelerating though still modest fertility transition (save
Palestine), and satisfactory socioeconomic and health
conditions. The last category of countries included Mauritania, Sudan and Yemen. These were economically poor
countries characterized by low rates of urbanization, female
literacy and doctors per 100 000 people, and excessively high
TFR, IMR and MMR.
Population- and hospital-based caesarean section rates for
the 18 Arab countries are also reported in Table 2. Yemen,
Mauritania, Sudan and Algeria had population caesarean
section rates below 5%. Palestine, Oman, Morocco, Libya,
Tunisia, Saudi Arabia, UAE, Egypt, Jordan, Kuwait and
Syria had caesarean rates ranging between 5–15%. Only
three countries had rates above 15%, namely, Lebanon,
Qatar and Bahrain. Eleven countries had hospital-based
4 697
13 803
3 041
3 347
18 3502
3 964
12 0982
1 563
3 305
15 8082
1 537
26 3042
10 766
1 331
2 892
4 870
19 935
719
3.3
2.6
3.4
4.7
2.9
2.3
3.8
6.0
3.4
5.9
5.9
3.7
6.2
4.9
4.0
2.3
3.2
7.6
TFR1
(children
per
woman)
50.0
16.0
51.0
27.0
12.0
20.0
28.0
97.0
52.0
27.0
25.5
14.0
25.0
86.0
27.0
30.0
12.0
74.0
1995
1995
2000
1995
1995
1995
1995
2000
2000
1995
1995
2000
1995
1995
2000
1995
1995
1995
IMR1 Year
(per
1000
live
births)
148
38
174
41
25
127
117
874
390
115
74
41
23
1 452
195
69
30
850
MMR1
(per
100 000
live
births)
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
1995
Year
84.6
100.0
202.0
166.0
189.0
210.0
128.0
13.8
46.0
133.0
–
126.0
166.0
9.0
144.0
70.0
181.0
23.0
No. of
doctors2
(per
100 000
people)
1995
1997
1996
1997
1997
1997
1997
1995
1997
1998
–
1996
1997
1996
1998
1997
1997
1996
Year
76.1
98.2
48.2
93.1
97.5
87.9
94.0
48.5
45.7
88.7
89.8
97.8
91.0
18.2
55.4
80.0
99.1
15.5
Institutional
deliveries3
(%)
4.9
16.0
10.3
10.5
11.2
15.1
7.2
3.2
7.0
6.6
6.1
15.9
8.1
3.7
14.8
8.0
9.6
1.4
6.4
16.3
20.9
11.3
11.5
17.2
7.6
6.6
15.3
7.4
7.0
16.3
8.9
20.4
–
10.2
9.7
6.3
Caesarean section3
—————————–
Population Hospital
(%)
(%)
Source: 1 UN PRED (2002); 2 WHO (2002); 3 Sources as in Table 1; 4 Palestinian Central Bureau of Statistics (2002); 5 UNFPA (2003). PPP = purchasing power parity.
49.4
79.4
43.9
79.3
76.4
76.9
60.4
32.1
36.1
50.5
83.9
83.1
59.7
38.8
60.5
53.3
74.3
18.4
27 655
573
67 884
4 249
1 691
3 169
4 755
2 665
29 878
2 154
3 191
565
17 091
27 213
16 189
8 943
2 352
14 895
Algeria
Bahrain
Egypt
Jordan
Kuwait
Lebanon
Libya
Mauritania
Morocco
Oman
Palestine4
Qatar
Saudi Arabia
Sudan
Syria
Tunisia
UAE
Yemen
56.6
90.3
45.2
71.4
97.0
87.5
85.3
57.7
56.1
75.6
67.45
92.5
82.8
31.3
54.5
61.9
83.8
23.6
Population1 Urban
Female GDP
(1000s)
Population1 Literacy1 (PPP)1
(%)
(%)
(US$)
Country
Table 2. Demographic, social, economic and health indicators for 18 Arab countries
1993
1995
2000
1997
1996
1995–6
1995
2000–1
1999
1995
1996
1998
1996
1993
2000
1995
1995
1997
Year
104
Rozzet Jurdi and Marwan Khawaja
C-section in the Arab region
caesarean rates below 15%. The rest of the countries had
rates ranging between 15.3% and 27.1%. A country like
Sudan, with a population caesarean rate below 5%, was
found to exhibit a hospital-based caesarean section rate of
20.4%, one of the highest in this category for the region.
Information by type of hospital for delivery was available for
only five countries in the region. The proportion of hospitalbased caesarean rates was found to be significantly higher for
women delivering in the private sector (22.6%) compared
with those delivering in the public (19.0%) in Egypt. Older
datasets for Jordan (JDHS 1990) and Morocco (MDHS 1995)
also revealed higher caesarean rates in private hospitals.
However, the converse was true for Yemen (4.7% and 6.6%)
and Palestine (9.0% and 8.7%), where caesarean rates where
higher in public hospitals.
Figure 1 shows the association of important socioeconomic
and demographic characteristics with population caesarean
section rates. Significant associations were found between
rates of caesarean section and urban population (rs = 0.637;
n = 18; p < 0.01), proportion of adult female literacy (rs =
0.715; n = 18; p < 0.01), GDP per capita purchasing power (rs
= 0.560; n = 18; p < 0.05) and TFR (rs = –0.585; n = 18; p <
0.05). In fact, Yemen and Sudan, poor countries with low
levels of urbanization and adult female literacy rates and high
TFR, showed some of the lowest population caesarean rates
in the region. Mauritania had a similar pattern despite its
relatively higher level of urbanization. On the other hand,
richer countries like Bahrain and Qatar, with their high levels
of urbanization and female adult literacy rates and their relatively lower TFR, exhibited the highest caesarean rates.
Egypt provided an exception to this rule. It was found to
exhibit higher rates of caesarean delivery than Oman,
Tunisia, Saudi Arabia, Libya and UAE, all with better socioeconomic profiles. Despite its relatively modest socio-demographic profile, Syria was found to have caesarean rates
similar to those of Lebanon, Qatar and Bahrain. Also interesting is the case of Kuwait. Even though it showed a better
overall socioeconomic profile than Lebanon (except for its
higher TFR), it was found to have a lower percentage of
caesarean deliveries. The rest of the countries were found to
follow to a great extent the aforementioned trend.
A significant association was also found between populationbased caesarean section and institutional deliveries, as shown
in Figure 1 (rs = 0.614; n = 18; p < 0.01). Arab countries with
caesarean rates below 5% showed lower proportions of
hospital deliveries. Yemen and Bahrain could best illustrate
this. Yemen, with the lowest institutional delivery rate in the
region (15.5%), exhibited also the lowest caesarean section
rate (1.4%), compared with Bahrain which had an almost
universal hospital delivery rate and a caesarean section rate
above 15%.
There were anomalies. With less than 50% of births delivered in hospitals, Egypt had a caesarean rate higher than
countries like Algeria, Tunisia, Oman, Palestine, Saudi
Arabia, Libya and UAE, where proportions of hospital births
were well above 70%. This pattern was observed in the case
of Syria as well. Similarly, the association between caesarean
rates and proportion of physicians (rs = 0.646; n = 17; p < 0.01)
105
was positive and significant (Figure 1). A statistically significant, positive relation was also found between caesarean
rates at the population- and the hospital-based levels (rs =
0.651; n = 17; p < 0.01). Bahrain, Qatar and Lebanon, all with
high population caesarean rates, also had the highest rates at
the hospital levels. The converse was true for Yemen, Mauritania and Algeria. Among the most interesting exceptions
were the cases of Egypt and Sudan, with hospital caesarean
section rates being two- and six-times higher, respectively,
than their population rates.
Figure 2 shows a strong, negative association between population caesarean section rate and IMR and MMR. Yemen,
Mauritania and Sudan with high IMR and MMR had the
lowest rates of caesarean section at the population level.
Again, Bahrain and Qatar, with their low IMR and MMR,
exhibited the highest population-based caesarean section
rates in the region. Despite having a relatively high maternal
mortality rate in comparison with Bahrain and Qatar,
Lebanon and Syria seemed to fit with this last group of transitional countries. UAE and Saudi Arabia could be regarded
as exceptions in this regard. Despite having very low IMR
and MMR, they showed lower rates of caesarean section
when compared with countries with relatively modest health
indicators like Egypt, Jordan, Syria and Lebanon. Although
Kuwait had impressive decreases in IMR and MMR, it
showed caesarean rates lower than countries with similar
characteristics like Bahrain and Qatar, or worse-off countries
like Lebanon and Syria. Countries like Jordan, Tunisia,
Libya, Morocco, Palestine and Algeria showed caesarean
rates in great conformity with their overall IMR and MMR.
Discussion and conclusions
Our results show that the Arab countries exhibited great
disparities in their population-based caesarean section rates.
These differences were explained to a great extent by the
countries’ demographic transition and socioeconomic
development. The strongest associations were found
between the prevalence of population caesarean section rate
and female literacy, percentage urban, IMR and the proportion of physicians per 100 000 people. Clearly, countries with
better socio-demographic and health parameters, as well as
better off economically, have been moving more quickly
towards a medicalization of maternal health care, through
specialized, high technology models.
Although higher caesarean section rates were found to be
associated with better health care and higher levels of socioeconomic development, there were exceptions. For example,
Saudi Arabia and Oman, being pronatalist countries with
high fertility rates, enjoyed high GDPs, levels of urbanization
and female literacy rates, and impressive improvements in
infant and maternal mortality rates. And yet, they had
average rates of caesarean section. At the other extreme
were Egypt, Jordan, Syria and Lebanon with rather high
caesarean rates for their overall levels of development. This
raises the question of whether these countries have been
undergoing over-medicalization of delivery or the ‘liberal’
use of the caesarean section procedure in recent years.
15
0
5
% Population CSR
10
% Population CSR
15
10
5
0
Sudan
20
Yemen
20
Yemen
Sudan
40
40
Syria
60
% Urban
Mauritania
Algeria
80
100
Palestine
Libya
Saudi Arabia
UAE
Kuwait
0
Yemen
Mauritania
Morocco
Tunisia
UAE
Egypt
50
Morocco
Sudan
Jordan
Oman
60
% Literate
Algeria
Libya
Jordan
Syria
Oman
Qatar
Mauritania
Palestine
100
150
Physicians (100000 people)
Algeria
Tunisia
Bahrain
80
Palestine
UAE
Kuwait
Jordan
Qatar
Lebanon
Bahrain
Egypt
200
Saudi Arabia
UAE
Kuwait
8
90
Lebanon
Yemen
Saudi Arabia
Tunisia Saudi Arabia
Libya
Oman
4
6
TFR (children per woman)
Libya
Syria
Qatar
40
Algeria
Kuwait
Bahrain
Lebanon
Sudan
2
20
Yemen
Sudan
Mauritania
Morocco
Egypt
Syria
15
5
0
5
Oman
Yemen
Mauritania
Algeria
Palestine
Libya
Saudi Arabia
Yemen
Sudan
Mauritania
UAE
Algeria
Morocco
Tunisia
Jordan
Lebanon
Palestine
Egypt
Syria
10
Libya
Saudi Arabia
% Hospital CSR
Tunisia
Kuwait
20
UAE
Kuwait
15
Morocco
Bahrain Qatar
Lebanon
Oman
Bahrain
10
15
GDP (int. $/1000)
Jordan
Figure 1. Bivariate associations between population-based caesarean section rates and indicators: Arab countries
60
% Institutional Deliveries
Oman
100
Bahrain Qatar
Libya
Jordan
Tunisia
Algeria
Kuwait
Saudi Arabia
UAE
Qatar
Lebanon
Bahrain
Lebanon
80
Oman
Jordan
Palestine
Tunisia
Morocco
Mauritania
Morocco
Egypt
Egypt
Syria
15
10
5
0
15
10
% Population CSR
% Population CSR
% Population CSR
5
0
15
10
5
0
% Population CSR
% Population CSR
10
5
0
15
10
5
0
20
Sudan
Egypt
25
Qatar
106
Rozzet Jurdi and Marwan Khawaja
100
C-section in the Arab region
107
Mauritania
60
Yemen
Morocco
Algeria
Egypt
40
IMR (1000 live births)
80
Sudan
Tunisia
Oman
Libya
Jordan
Saudi Arabia
20
Palestine
Syria
Lebanon
Bahrain
UAE
0
5
Kuwait
10
Qatar
15
1500
% Population CSR
MMR (100000 live births)
1000
500
Sudan
Yemen
Mauritania
Morocco
0
Libya
Algeria
Oman
Tunisia
Palestine
UAE
Saudi Arabia
0
5
Egypt
Jordan
Kuwait
10
Syria
Lebanon
Bahrain Qatar
15
% Population CSR
IMR
MMR
rs
= –0.743**; r s
= –0.579*. **Correlation is significant at the 0.01 level (2-tailed);
*Correlation is significant at the 0.05 level (2-tailed).
Figure 2. Bivariate association between population caesarean rates and mortality outcomes: Arab countries
108
Rozzet Jurdi and Marwan Khawaja
All in all, however, the findings reveal that the ‘caesarean
section epidemic’ (Sakala 1993) found in countries of Latin
America is not yet evident in the Arab region. Rather, efforts
need to be undertaken to promote better access to caesarean
section in some countries. Specifically, Yemen, Mauritania,
Sudan and Algeria had caesarean rates well below 5%, indicating possible problems in accessing appropriate obstetrical
interventions in case of complications during delivery. These
countries are largely rural, exhibiting great regional disparities in health conditions and socioeconomic development.
Access to appropriate obstetric care in remote areas in these
countries may help reduce both infant and maternal mortality rates encountered in these areas. Again, however, as
Buekens et al. (2003, p. 136) put it, ‘any support programs [in
this direction] should be carefully designed to avoid the risk
of simultaneously increasing unnecessary caesarean section
and iatrogenic morbidity and mortality.’
Clear differences between population- and hospital-based
caesarean section rates were also documented, especially in
countries with very low overall rates of hospital deliveries.
This may reflect differences in accessibility to maternal
health services in some cases, or the misuse of scarce
resources in others. High rates of caesarean section at the
hospital level compared with only modest rates at the population level, as was the case in Sudan, pose questions regarding the proper use of this surgical procedure.
Differences in caesarean rates between private and public
hospitals were also evident in some countries. Bearing these
results in mind, we cannot but wonder whether the higher
proportions of caesarean section deliveries in private hospitals are really a reflection of physicians’ efforts to ensure
better outcomes in case of complications, or whether their
decisions are affected by profitability or factors relating to
physicians’ convenience. Although we lack systematic information on health care financing by place and mode of
delivery for the countries under study, some general observations are in order. First, obstetricians are generally paid
more for a caesarean delivery than for a vaginal delivery.
However, payments differ greatly between countries and
between hospital types within the same country. Secondly,
institutional deliveries are handled mostly by physicians, but
deliveries by trained nurses/midwives are also common.
Again, differences exist between and within countries. For
example, a country like Egypt, characterized by a shortage in
trained nurses/midwives, has a higher proportion of institutional deliveries handled by doctors (Eltigani 2000). Data
for Jordan reveal that assistance during delivery in a hospital
setting varies greatly, with about 65% of deliveries being
assisted by a doctor and 32% by a trained nurse/midwife
(Department of Statistics [Jordan] 1998). Furthermore,
doctors are more likely to assist births to educated women,
to women in urban areas and to women who received more
antenatal care (Department of Statistics [Jordan] 1998). The
opposite is true for Syria and Palestine, where a significant
proportion of institutional deliveries are handled by trained
nurses/midwives (Central Bureau of Statistics [Syria] 2002;
Palestinian Central Bureau of Statistics 2002).
Thirdly, the mode of payment of physicians in these countries
depends greatly on the setting and the availability of health
insurance in each country. In most cases, there are out-ofpocket payments if the women are not insured or are only
partially insured. Although some countries have only public
insurance coverage (e.g. Syria), most settings have both
private and public sectors providing health insurance. Further
research is needed to establish the precise causes of hospitalbased caesarean section, and to unmask the mechanisms
underlying the practice in private and public sector hospitals
in the region and beyond. A detailed comparison of health
care financing in these countries by type of hospital may
provide answers to some of the observed differences.
When considering the implications of our findings, the usual
shortcomings of the study design need to be acknowledged.
This is an ecological study based on comparative nationallevel data collected at different points in time in different
countries. As such, it may explore hypotheses but it cannot
explain associations. Hence, the study relied on bivariate
associations rather than multivariate analyses. Given the
small sample size and the data at hand, we chose to use correlation analysis between caesarean rates on the one hand and
selected development and health indicators on the other.
Confirmation of our findings using multivariate statistical
techniques and better, or otherwise more current, development indicators will be necessary.
Our study may have several other related limitations. One
major weakness pertains to the quality of the data used. The
data used for the national-level demographic and socioeconomic indicators varies from source to source, despite
efforts by the UN agencies to ensure comparability (UN
PRED 2002). Problems of obtaining data at the same point
in time for all indicators under examination may have also
affected the validity or the comparability between the countries under examination. Nevertheless, the UN agencies
provide the most recent and comparable statistical series at
the national level – there is simply no other, more credible,
source of demographic and health characteristics of countries. Another weakness relates to the estimation of population-based caesarean section rates for some countries.
Owing to the lack of appropriate data, we had to estimate
caesarean rates using information from published reports for
some countries. Here, we assumed that non-hospital deliveries were all vaginal deliveries (Belizan et al. 1999). Although
our assumption may be a valid one, the exact correspondence
between our estimates and the actual figures remains difficult
to assess. Finally, we were not able to consider another set of
factors related to health care financing and profitability that
might have accounted for some of the observed associations
between caesarean section delivery and development indicators.
This study has left many other important questions unanswered. The Arab region is clearly diverse in terms of
maternal health and obstetric care, as demonstrated in this
profile of caesarean section delivery, but intra-regional variations mask important intra-national differences in maternal
health outcomes, including childbirth. It is unclear, for
example, whether the variations observed among countries
are due to within country differentials in access to health
C-section in the Arab region
care or to overall ‘deficit’ in health care coverage. What are
the precise socioeconomic and demographic factors
contributing to the deficit (if any) in utilizing maternal
health care in specific contexts? Can low rates of caesarean
section delivery be attributed to cultural preferences for
traditional or otherwise home-based delivery in some countries? To what extent are the high levels of caesarean section
observed in countries like Egypt, Syria and Lebanon due to
the development of policy concerns and heightened awareness about maternal mortality and morbidity? Do levels of
caesarean section reflect the recent trend towards privatization or otherwise lack of regulation of the health sector in
the region (Campbell and Lewando-Hundt 1998)? Answers
to these and similar policy-relevant questions require the use
of carefully designed qualitative studies, as well as the utilization of micro survey data, which have become recently
available.
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Rozzet Jurdi and Marwan Khawaja
Acknowledgements
This paper is part of a larger regional research project on Changing
Childbirth in the Arab Region, sponsored by the Center for
Research on Population and Health at the American University of
Beirut with support from the Wellcome Trust and Mellon Foundation.
Biographies
Unit
Thousands
Percentage
Percentage
Children per woman
Deaths per 1000 live births
Deaths per 100 000 live births
Current international dollars
Rate per 100 000 people
Total population1
Percentage urban1
Adult literacy rate, female1
Total fertility rate1
Infant mortality rate1
Maternal mortality ratio1
GDP per capita at purchasing
power parity (PPP)1
Health personnel2
Marwan Khawaja, Ph.D. (Cornell University), is an Associate
Professor of Population Health and Director of the Center for
Research on Population and Health in the Faculty of Health
Sciences at the American University of Beirut. He is currently
coordinating a major research initiative on displacement, impoverishment and urban health in outer Beirut, including a large household survey undertaken in 2002. He has published numerous
research reports and articles.
Variable
Definition of variable
Rozzet Jurdi, MS (American University of Beirut), is trained in
demographic techniques and statistics. She is currently a Researcher
in the Center for Research on Population and Health in the Faculty
of Health Sciences at the American University of Beirut. She is
presently engaged in two projects namely, Changing Childbirth
Practices in the Arab Region and Provider’s Study on Sexual Health
in Lebanon. Her research interests include woman’s obstetric care
and experience, reproductive morbidity, infertility and other issues
of public health concern.
Appendix. List of variables used
Correspondence: Dr Marwan Khawaja, Center for Research on
Population and Health, Faculty of Health Sciences, American
University of Beirut, P.O. Box 11–0236, Riad El-Soloh/Beirut 1107
2020, Lebanon. E-mail: [email protected]
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under 1500 grams. Journal of Obstetrics and Gynecology 20:
389–91.
Mid-year de facto population estimated by the Population Division/DESA of the United Nations Secretariat.
Estimates and medium-variant projections provided by United Nations.
Estimates of the percentage of total population residing in urban areas provided by United Nations. ‘Urban’ is
defined according to the national census definition used in the latest available population census in each country.
Female adult literacy refers to the proportion of the female population aged 15+ years who can, with
understanding, both read and write a short simple statement on everyday life. Estimates provided by UNESCO.
Average number of children that would be born to a woman in her lifetime, if she were to pass through her
childbearing years experiencing the age-specific fertility rates for a given period. Estimates and medium-variant
projections provided by United Nations.
Number of deaths of infants under 1 year of age per 1000 live births in a given year. It shows the probability of a
newborn dying before reaching his first birthday. Figures are quinquennial estimates and medium-variant
projections provide by United Nations.
The maternal mortality ratio is the number of maternal deaths over a year per 100 000 live births in that year.
GDP per capita at purchasing power parity (PPP) are GDP estimates based on the purchasing power of currencies
rather than on current exchange rates. These estimates are a blend of extrapolated and regression-based numbers
provided by the World Bank.
Number of physicians, nurses, midwives, dentists, pharmacists per 100 000 population per year provided by WHO.
110