When she became pregnant for the first time, Malak al-Assaui wanted above all a natural birth - but her doctor in Egypt had a different plan, she suspects.
"Before my due date, he started convincing me that I would give birth to this baby by Caesarean section," the 35-year-old says.
And that's exactly what happened - as it did again with the birth of her other two children.
To this day, al-Assaui wonders whether her children could have been born naturally and whether the procedures were medically necessary.
"I only remember that they left me no choice. They did not even try," she says of the first birth. When her water broke and she asked at the hospital to try naturally first, the doctor replied: "Your Caesarean appointment is tomorrow."
There are few countries in the world where more children are born by Caesarean section than in Egypt. According to the study "The Rising Global Cesarean Section Rates and Their Impact on Maternal and Child Health" published in 2025 in the Journal of Clinical Medicine, the five countries with the highest Caesarean section rates globally were the Dominican Republic (58.1%), Brazil (55.7%), Cyprus (55.3%), Egypt (51.8%) and Turkey (50.8%). The figures are based on data from 2018.
In Europe, Romania had the highest rate at 46.9% and the Netherlands the lowest with 14.9%, the study shows.
Egypt's official figures are even higher with the Caesarean rate in 2021 at 72%, the latest official figures show. In Port Said, which sits on the Mediterranean some 200 kilometres north of Cairo, statistically only one in 10 children is born naturally. The federal government in Cairo is trying to counter this. A Caesarean can save lives, but it can also harm mothers and children if it is not medically necessary.
A global trend
The World Health Organization (WHO), which for a long time recommended a maximum Caesarean rate of 10% to 15%, speaks of a global trend with different causes depending on the country.
The Journal of Clinical Medicine study says the continuous increase in C-sections, as they are commonly known, "suggests that by 2030, global rates may reach 30%." While it expects the current low rates in Sub-Saharan Africa to remain below 10%, in regions like Eastern and Western Asia and Latin America the surgery "may become the dominant method of delivery."
"Many, many patients in Egypt and in the Arab region ask for a Caesarean," says Jusra Laschin, who runs a gynaecology practice in Cairo. "They do not want pain in the middle of the night. They do not want surprises." These women would rather have a planned event, a "perfect room with balloons and chocolate and putting on make-up for a photo session" after the baby arrives, Laschin says.
Economic pressure is also a reason
That may be true for some mothers. But Egypt's doctors also like to reach for the scalpel during birth for very different reasons.
First there is the pay: In the growing number of private hospitals, doctors often earn more from a Caesarean and critics sometimes speak of "a greed for profits." Under economic pressure, many work in parallel at several clinics and can plan better with Caesareans. The procedure itself often takes only 15 minutes, so a doctor could perform 10 or more Caesareans in the time it takes for a single natural birth.
That is how gynaecologist Sharif Hamsa describes it too. "With the first baby, you wait on average six to 12 hours." A doctor with several jobs and a private life therefore asks: "Why should I do that? I do a Caesarean and go home." Midwives, who are common in many European countries, are rare or do not exist at all in Egypt.
'If something goes wrong, it is the doctor's fault'
The country is grappling with a severe economic crisis and a third of the population lives in poverty. Care in state hospitals is poor and there is often a lack of equipment to monitor the baby's heartbeat, for example. Blood banks are often empty or do not exist. Natural births can therefore also mean risks. Those who can, go to a private clinic and many pay out of pocket.
Legal issues also play a role. Doctors face prison sentences if a natural birth leads to complications or even the death of the baby or mother, even if doctors strictly follow protocol.
"If something goes wrong, it is the doctor's fault," says Hussein Gohar, one of the best-known gynaecologists in Cairo. Many colleagues therefore practise "defensive medicine."
Egypt is trying to reduce the amount of legal claims. Hospitals now have to document when a Caesarean was carried out and why. There have recently been inspections at several clinics in the capital. Costs are to be standardized and midwives are to be trained in future. There are also private campaigns intended to inform women and encourage them to decide for themselves.
Expert: 72% rate is 'not medicine'
Expert Alexandre Dumont describes the 72% rate as alarming. "It is unbelievably high. That is not medicine and not compatible with the Hippocratic oath" of doctors not to harm patients. Dumont, who researches the topic at Sciences Po University in Paris, has launched a project intended to strengthen the self-confidence of pregnant women.
In less developed countries, women often cannot decide freely on the question, Dumont says. "The doctor has power, he is highly respected. He is part of the upper social class, wealthy and educated." Women from poorer classes are easily persuaded to have a Caesarean. "This relationship is not fair. The woman should be able to help decide," Dumont says.
No classes for expectant mothers, no midwives
"There is no system, no appropriate counselling for women, no pre-natal classes and very few to no midwives," gynaecologist Gohar says. In addition, epidural anaesthesia and other pain relief are often not available or are expensive. All the more widespread is the fear of birth, which 70% of expectant mothers in Egypt feel, according to a 2024 study. In western countries, the figure is 5% to 15%.
Reversing the trend could take years. The younger generation of doctors is particularly needed, but "they have no experience of the complications of a normal vaginal birth at all," Gohar says. Training is tending towards Caesareans.
