The day her daughter was born was the most traumatizing of Alaa’s life. After being talked out of a water birth and told her cervix was too narrow for a natural birth, the 25-year-old picked a sentimental date for her reluctant C-section, got her hair and makeup done to look good for the photos, and prepared to celebrate a momentous day with her family.
Instead, Alaa’s experience was marred by many of the issues that — even as they’re rejected by many doctors as unethical — have become standard practice in maternal healthcare in Egypt.
“I felt like I didn’t have power over my body,” Alaa told New Lines. “My experience in the OR was the most humiliating of my life. No one was telling me what was going to happen. Suddenly my gown was ripped off, a catheter was put in, no one was explaining the process. I felt so violated. Later, when the nurse was checking up on me and it hurt so bad I screamed, everyone held me down to let him do his job. I didn’t understand why I was being tortured after I had just come out of surgery.”
The absence of consent before performing procedures, the lack of proper counseling on different modes of delivery, privacy violations (including a sense of entitlement over the mother’s body) and the dismissal of physical pain are all ways that women report being routinely mistreated during pregnancy and childbirth, and are by no means unique to Egypt.
Obstetric violence affects women worldwide, in both the North and South. And though it remains a taboo subject, the issue of disrespect and abuse in maternity care is increasingly being discussed and researched, including in the Middle East. Around the world, the broader strokes of patriarchy — including a tendency to disbelieve women, entitlement over women’s bodies and abuse of power — inevitably come to a head during childbirth with disturbing results.
Nour Emam is an Egyptian birth doula, sex educator and founder of Mother Being, a groundbreaking platform for sexual health and reproductive education that has garnered significant popularity for its remarkably destigmatizing, often humorous Arabic content on historically taboo topics including sexual pleasure, contraceptives and vaginismus.
According to her, the sequence of events that leads a woman to feeling so deeply violated, as Alaa did, begins much earlier than delivery. Emam, who herself felt cornered into both an early induction and an unnecessary C-section, says women are often encouraged, manipulated or coerced into cesarean deliveries, regardless of their birth plans. Women themselves increasingly communicate a preference for C-sections but very rarely receive counseling on risks and benefits. Perceived as “cleaner,” quicker and more convenient, cesareans are also more expensive, invasive and health-altering than a vaginal delivery for both mother and baby, as some C-section newborns develop pulmonary and other health issues that would otherwise be avoidable in a vaginal birth.
Yet according to the latest available data, 52% of all births in Egypt are C-sections, over twice the global average and several times higher than the ideal rate (10-15%) recommended by the World Health Organization (WHO). Jordan, in second place among Arabic-speaking countries, comes in at 28%, according to the 2017-18 Jordan Population and Family Health Survey.
Egypt’s own rate further increases to 60% in urban areas, and the rate in Cairo hospitals can jump up to 94%, according to a 2018 multi-tier study by Population Council, an international NGO, in collaboration with Egypt’s Ministry of Health and Population, the United Nations Population Fund (UNFPA) and WHO. The study — which looked at Egypt Demographic Health Survey (EDHS) data, medical records, 484 case reviews in 16 hospitals in four governorates, 325 physician interviews and 12 focus group discussions with 96 pregnant or postpartum women — remains the most exhaustive collection of research on the issue.
The sheer scale of the numbers recorded suggests that C-sections — a life-saving option when necessary — are more often than not performed for nonmedical reasons. Johns Hopkins University doctoral candidate Shatha El Nakib, who was on the core team for the Population Council study, says the staggering rate in Egypt is a result of the overmedicalization of the birthing process over the past two decades — an observation that many Egypt experts agree upon.
“What happened over the past 20 years is that a lot of women went from giving birth at home to giving birth in hospitals,” says Dr. Nahla Abdel Tawab, senior associate and Egypt country director at the Population Council. “That’s a good thing obviously, but personnel and resources didn’t rise to meet that need.”
Positive results of the medicalization of childbirth, Abdel Tawab and her team make clear, are undeniable. By 2016, about 92% of deliveries in Egypt were attended by a skilled birth attendant, up from 46% in 1995. Maternal mortality rates dropped to 45.9 deaths per 100,000 live births, from 174 in 1990. So why is it an issue at all that more and more women are having C-sections instead of delivering naturally, if the latter seems to be correlated with better overall health outcomes?
El Nakib says zooming in to see the health effect on the individual woman and zooming out to see the burden on the healthcare system provide two important answers. “The medical answer is that women are undertaking unnecessary surgery, which carries complications for both mother and newborn. And we’ve found that most of the time in Egypt, cesareans are done for unnecessary indications. You’re making a woman undergo a surgical operation when she shouldn’t have to.”
To look at the bigger picture, she continues, is to see how the overmedicalization of the process has created an immense burden on an already overloaded system. Birthing in Egypt is completely dependent on doctors, with no task shifting to midwives and nurses. Standard practice in many countries, training midwives and nurse practitioners would, according to El Nakib, significantly decrease the drain on resources. In 2014, Population Council’s study calculated that unnecessary C-sections cost the Egyptian healthcare system a total of about $60 million, while the total healthcare budget at the same time was about $270 million.
Why then, if these gigantic numbers seem to be both straining the national healthcare system and putting women and newborns in unnecessary surgery, have cesareans become the default mode of delivery in Egypt, particularly in more affluent urban centers?
Even for experts, the answer is difficult to pin down. A number of factors — including social pressures pushing women’s preference for C-sections, lack of rigorous protocol and oversight, a financial incentive from both doctors and hospitals, a competence factor that doctors are increasingly better trained for cesarean deliveries and an overwhelming convenience narrative — seem to be pushing the rate up. Critically, the 2018 study found that doctors consistently hold the most power in the process.
Without updated and enforced medical protocols, the decision to perform a cesarean is largely left to physicians’ discretion. Doctors often cite subjective indicators, such as fetal distress or suspected macrosomia (excessive birth weight), without including exact measurements, with little functional oversight. Some 9% of the medical records examined in the study, all of which were from public hospitals, did not include a documented medical indication at all.
While multiple factors — including overcrowding, resource shortages and litigation fears — come into play in public hospitals, profitability is cited as the main propeller in the private sector. Cesareans cost more (though vaginal deliveries are catching up), so they have naturally become a favorite for both doctors and hospitals, who unlike with a vaginal delivery can charge well above the cost to them. Though the study cites an average charge per C-section of about $125 to $300 at private facilities (compared with vaginal deliveries closer to $60 to $125), women report paying from about $1,000 to almost $3,000, which includes the hospital stay, operating room charges and the doctor’s fee, which is paid directly to the doctor and colloquially referred to as “the cost of the hand.”
“Rates of C-sections are up all over the world, not just in Egypt,” says Dr. Mirna Awad, an OB-GYN who works at both a private and public hospital. “The difference is that in a lot of countries, most deliveries are happening with government funding. In Egypt, most of the country is giving birth in the private sector, even if at the lowest-tier facilities.”
Most mothers, regardless of socioeconomic background, prefer delivering with private providers who are seen to offer higher quality, more hygienic, and more patient-centric care. The private sector, which as indicated by the study has a profitability incentive to encourage cesareans, is 2.17 times more likely to deliver via C-section. According to the 2014 EDHS, 60% of babies born in Egypt are delivered in the private sector, despite accounting for only a quarter of total inpatient bed capacity.
One of the main reasons for choosing a C-section as mentioned by doctors, researchers, and mothers is convenience. With mother and baby in and out in an hour, C-sections mean mothers don’t need to worry about labor taking them by surprise, and doctors can schedule several in one working day, instead of monitoring one patient for hours. An OB-GYN who has an overload of patients can make sure not to be hung up in a delivery if another patient goes into labor.
“Having worked as a doula, I understand why C-sections get attractive,” Emam says. “They’re predictable. With natural birth, you’re on call, your life is on hold. So I get the human side of doctors feeling like they need some security.”
The problem becomes when this natural preference for control is married with an abuse of power, as May ElShamy, journalist and founder of the Facebook page Stop Unnecessary Cesareans, thinks it often is. Though ElShamy’s own doctor coached her through the natural birth of her son, she says most women aren’t so lucky.
One story she says pushed her to start the Facebook page and raise awareness, was a woman whose doctor told her to come in for a C-section because the following week was Eid, he won’t be available, and she would end up having to give birth in a public hospital. The doctor, ElShamy says, is quite famous in his city and owns a hospital himself.
Emam says there are a million stories of this kind. A doctor once told one of her clients that they would have to induce if she didn’t go into labor by the end of the week, because the doctor’s son’s wedding was that weekend.
Emam says her own story, of having an unsuccessful induction at 39 weeks, is one of the gentler ways that doctors maneuver a woman into a cesarean. “They did it before I was ready, before my body had started laboring naturally,” Emam recalls. “It wasn’t going well, and I was told, ‘Oh, we can be patient. You can stay in the hospital for as long as it takes; we’re prepared to be here all week.’ But you’re using this language with a woman who has been put into labor for 24 hours, who’s exhausted, who’s not dilated, who’s very disheartened. Of course I said, ‘Give me a C-section. I want this over with.’ They end up cornering you into having only one option.”
Many of Emam’s clients, she says, are told in one of their final checkups to come in a couple of days after for a scheduled C-section, for any number of reasons, including that their amniotic fluid is too low. “My response is always that if it was really an emergency, he wouldn’t dare schedule the C-section; he would tell you to meet him at the hospital right now because it’s dangerous.”
In light of exceedingly common stories like this, ElShamy elaborates on why she intentionally uses the word “violence” to describe the dynamic. “When a doctor manipulates a mother who’s tired and scared and close to term, and tells her something like ‘the amniotic fluid is low,’ without saying how low … when you exploit a woman, cut through seven layers of flesh just so you can make more money or go home earlier, that’s violence.”
Both ElShamy and Emam agree that elective cesareans aren’t the issue and can be a great option for many women, including those who have been exposed to sexual trauma or female genital mutilation (FGM), or for no other reason than personal preference. The problem, they say, is that women aren’t presented with all the necessary information before choosing their preferred mode of delivery.
When asked, many doctors — both as reported in Population Council’s 2018 study and when New Lines spoke with them — say that it’s women who drive up C-section rates by specifically requesting them. Increasingly, women — including many who participated in the study’s focus group discussions — say they prefer the quick, sanitized in-and-out of cesarean delivery (which is also seen to be more prestigious) to a prolonged, messy vaginal birth.
As a kind of snowball effect, because more and more women are getting C-sections, it has become the cultural default. “In a lot of cases, I think women opt for them because they’re the norm now,” Emam explains. “Her cousin had a C-section, her friends have had C-sections, most of the women around her have. So she has little to no reference of someone who’s had an undisturbed natural birth.”
“Doctors say that it’s women who want C-sections,” El Nakib says. “But have you done pre-delivery counseling? Did you tell her what she can expect with a vaginal vs. cesarean birth? Did you objectively present her with all her options? Is she making an informed decision, or are you pushing her into one mode of delivery?”
Only 6% of women El Nakib and the study team interviewed reported receiving any sort of counseling on the disadvantages and health risks of a C-section. Ultimately, the study found both an absence of an informed consent process and limited involvement of women in the decision-making process.
ElShamy, Emam and El Nakib all mention that the fact that doctors seem to be the only real voice in the process is likely a result of the culture that surrounds the profession. Interpersonal skills and physician-patient communication remain undervalued attributes, and that goes for both male and female doctors.
“I don’t necessarily blame the doctors,” Emam says, referencing the toxic environment of medical school, often overloaded schedules, and a crushing financial system. “But it’s become normal for them not to answer women’s questions, to tell them they don’t have time. If a woman asks questions or challenges her doctor, I’ve heard jokes like, ‘What, are we going to become friends here?’ or ‘Would you rather deliver your own baby instead?’ ”
On the other side, women are under immense pressure to do right by their baby and family. They’re often exhausted and scared, and look to their doctors for guidance. Timing their delivery with a C-section is attractive, because it ensures family members can be around. Women also worry about the pain of natural childbirth as well as the availability of epidurals and on-call anesthesiologists to administer them.
They also, often catastrophically, worry about the effect a natural birth and a potential episiotomy (a cut between the vagina and perineum made when necessary to widen the vaginal opening and prevent tearing) can have on their vagina and, consequently, their sex lives with their husbands. Many doctors, ElShamy says, aren’t shy about encouraging C-sections for this reason as well.
“And then you see it a lot on Facebook groups for wives and mothers,” ElShamy says. “Women scare each other, that your sex life will end, that your husband will leave, that you’re going to get divorced if you have a vaginal birth.”
El Nakib, who uses the word “mechanical” to describe all-too-prevalent attitudes toward childbirth, says that women should be advocating for themselves more in the process. Without information however, that advocacy for your family’s birth preferences is impossible, which is why platforms like Emam’s Mother Being are so important.
“I think it’s wonderful; she’s spearheading a movement,” El Nakib says of Mother Being. “She has a massive following, and she talks about the exact things women should be hearing. And I don’t think there’s any other avenue for women to get the kinds of messages that she’s sending across.”
Over the past few years, as more and more women have spoken up about their birthing experiences — including non-consensual procedures, feeling coerced out of their birth preferences and not feeling prioritized in the process — social media culture has begun to see a slow shift, with initiatives like Emam’s and ElShamy’s spurring the conversation and emphasizing the need for women to advocate for themselves.
ElShamy, who initially feared that the page would get no engagement at all, receives messages and comments from women asking her for advice, which the page’s consulting doctor answers as best she can. However, she also has women accusing her of unfairly scaring them out of their scheduled C-sections.
“Our role is to provide the information that’s in the medical research but that you might not have access to, either because it’s unavailable or in English or targeting doctors,” ElShamy says. “I take the information and I write it in a way anyone can understand. If you don’t want to read it, you can always scroll away. But this is information that anyone about to give birth needs to know; you can’t go into an experience like that with no idea what to expect.”
Information, Emam says, is the crux of the matter. “I’m not anti-cesarean sections, I’m just pro informed choice. If you are fully aware of the risks and benefits to whatever mode of birth you’re choosing, you have the right to make that decision. It is your body.”
As it stands, this concept of bodily autonomy seems to be sorely lacking. Maternal healthcare, contextualized as it is both within the healthcare system and a deeply patriarchal society, is not currently characterized by women and doctors jointly making informed decisions about what’s best for mother and baby.
With initiatives like Emam’s and ElShamy’s, more doctors advocating for better practices, as well as a growing culture of ownership and advocacy among expectant mothers, a cultural shift might be underway, bringing with it better outcomes for healthcare, newborns and expectant mothers like Alaa.