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Written by Marianne Roux
Girt with pastel tulle and adorned with a cluster of pink and white balloons, the door displays a Welcome Baby girl with the name “Dalila” in glittery fuchsia letters, contrasting with the pale neon lighting. Taken at the maternity clinic and posted on Facebook, the photo will serve as an announcement to the families and friends of the new parents.
Dalila is one of the 3,636 babies born daily in Egypt, and like the majority of them, she was born by Caesarean section. Over about twenty years or so, in the country the rate has increased from 4.6% to almost 60% today, ranking third in the world for this practice, behind the Dominican Republic and Brazil.
Let us recall that a C-Section is a surgical procedure used to deliver a baby through incisions in the abdomen and uterus. The latter is usually performed when there are pregnancy complications, for the mother or the child, which are not favorable for a vaginal birth. A C-Section can be planned ahead of time but it can also be the result of an emergency situation. Although it is a frequent technique, it is not necessarily trivial.
Alerted by the regional discrepancies observed across the world, in 2015, the WHO released a statement indicating that the optimal rate of C-Sections is between 10 to 15%. Indeed, while the practice helps avoid excess maternal and prenatal mortality, extensive use of it, as is currently the case in Egypt, does not provide any additional benefit. Worse, it can be associated with short and long term risks for women, especially during their future pregnancies as well as for children.
At first glance we associate a high rate of Caesarean sections according to the degree of national development. However, the reality is quite different since some of the richest countries and the best equipped in terms of public health like Japan or the Scandinavian countries maintain rates below 20% [1]. In the most populated Arab country, this boom can be explained by a combination of factors, first and foremost the predominance of the private sector and the lack of regulation by the authorities in terms of public health.
The predominance of the private sector
In the 1980s, the majority of Egyptian women gave birth at home, surrounded by a traditional birth attendant (daya) or even a member of the medical profession. From the 1990s onwards, the percentage of births in medical establishments continued to increase, reducing the risks for women in labor and babies. It was during this same period that the private sector imposed itself as the population has quite a negative perception of the public hospital. It is important to mention that this phenomenon concerns all social classes, even modest ones, as well as the whole territory, regardless of the level of education. Indeed, mothers would rather go into debt than give birth in an environment they consider unsafe.
Egyptian women have more trust in private clinics for the monitoring of their pregnancy and care on the day of delivery. Except that in practice, this support does not guarantee a more attentive listening to their interests and their needs. On the contrary, practitioners very often impose their views and abuse their position.
According to Doctor Nadia Ali [2], obstetrician-gynecologist who graduated from the Alexandria Medical University, this situation results from a cycle that seems difficult to stop.
“When I was a student at university in 2012, the caesarean section was already considered the norm. Our teachers trained us on this practice, which they themselves use in the clinics where they practice. Even after our internship and graduation, the reality is that we have rarely witnessed a natural birth, especially in the private sector,” Doctor Nadia recalls.
This lack of experience fuels fear among young doctors and many do not feel able to cope with the complications that could eventually arise during a natural childbirth. However, Nadia Ali assures us that this is unfounded.
“It was when I expatriated to Saudi Arabia that I rediscovered my practice. Here, the health insurance system is such that a C-Section cannot be performed without medical justification. I realized that vaginal birth is not complicated and that the potential difficulties are quite manageable. Like any surgical skill, the practitioner comes to master it with experience. Our patients deserve a natural childbirth attempt. There is no doubt that it is best for them and their children,” she explains.
A C-Section is often charged twice the price of a natural childbirth, not to mention the comfort of the practitioner who schedules the day of the birth in advance, thus avoiding to be on call at night or during weekends or face extended hours.
Priority to the comfort of the practitioner
Besides this real lack of training, there are also significant financial and organizational aspects. Indeed, a C-Section is often charged twice the price of a natural childbirth, not to mention the comfort of the practitioner who schedules the day of the birth in advance, thus avoiding to be on call at night or during weekends or face extended hours.
The combination of these factors has led to the explosion of C-Sections across the country. In a long personal article published on the Mada Masr website, journalist Yasmin El-Rifae describes her rocky path to ensure the most natural birth possible for her baby. Expressing her wish to her gynecologist, the latter replied, “You can try of course. But did you know that it is the most excruciating pain after that of a total body burn?”
This testimony is unfortunately not an exception but rather the dominant discourse in Egypt. Sarah who gave birth to twins 8 years ago confirms that she had no preconceptions about childbirth:
“Before going to see the obstetrician, I thought I was going to give birth naturally. The latter clearly advised me against it, telling me that it was risky with twins. I listened to him but didn’t get enough information or feel like I had a choice. I didn’t expect to have so much pain after my C-Section. I wasn't warned. The staff forced me to get up an hour later so that I could go home the next day. I had terrible pain for a week and didn't feel able to take care of my sons.” When her sister gave birth naturally three months ago, Sarah was amazed to see that the next day she could walk normally and enjoy her daughter to the fullest.
Gynecological violence and the lack of sexual education
Caesarean sections carried out for the comfort of the practitioner and not the mothers are akin to gynecological violence. Even when women express their desire to give birth naturally, they almost always find themselves unable to do so. Stressed and exhausted from the last days of pregnancy, they prefer to rely on their doctor’s advice when the latter discusses potential risks, not knowing whether he is telling the truth or not. Others succeed in giving birth vaginally but have their contractions medically triggered because the practitioner wants to control the day of birth, without this being justified due to exceeding the term.
The system treats the pregnant woman like a patient who must listen to her omniscient doctor. In a society where sex education remains a taboo, women have no access to information that could allow them to make informed choices. Doctors know this and take advantage of the situation, in defiance of professional ethics.
Instead of helping women make their choices, making them full actors of this crucial moment in their life, they diminish them by telling them their bodies are not able to endure this suffering, that their pelvis is too narrow, and that childbirth may harm their sex life and the pleasure of their husbands.
Moreover, the representation of childbirth in audio-visual productions and the influence of the stories of their mothers and other older women of the family (who gave birth without an epidural) fuel a fear among young women who feel vulnerable and therefore choose what is presented to them everywhere as progress, an advantage of “modernity”. Their friends have usually experienced it and their husbands appreciate the freedom of being able to choose the date of birth, finding it more convenient.
Caesarean sections carried out for the comfort of the practitioner and not the mothers are akin to gynecological violence.
The ultra-medicalized pregnancy monitoring is by no means qualitative and this is where the problem lies. Like Amy, women who make sure to find a pro-natural childbirth practitioner are also often left to fend for themselves: “I was able to give birth vaginally but I had no childbirth preparation classes, I just did research on the internet. After giving birth, I suffered from baby blues and I would have liked to talk to someone, to get advice on breastfeeding...”
Hend, who had four children, two of which by vaginal delivery, found herself in the labor room with a team that neither informed her of what was going on nor asked her for her consent.
“At one point they gave me gas but without telling me what it was. I thought I was going to suffocate when it would have been enough to explain to me that it was to relieve the pain and that it would work in three minutes,” she says.
Having a C-Section without knowing the consequences or the risks in a country where women have an average of 3 children is problematic. Especially since they are told that if they have had a first caesarean, other births will not be able to occur in a natural way, which is not medically justified. Obviously, patients are not aware that C-Sections are associated with greater difficulty in breastfeeding and a higher rate of postpartum depression, not to mention the repercussions for the child, particularly in terms of the immune system.
Where are the midwives?
In Egypt, we choose the doctor who will assist us on the day of delivery - and not the establishment - and the latter remains the only professional with whom we are in contact, thus establishing a bond of extreme dependence. Note that he or she too is dependent on the internal policies of clinics, which are often pro-caesarean. In fact, the real weak link in the Egyptian system is the absence of midwives who, in other countries, provide the essential support required in the preparation for delivery and reception of the baby.
Mohamed Ali opened a midwifery school in Cairo in 1832 directed by the Frenchman Antoine Barthélemy Clot-Bey. Nevertheless, as the historian Laure Pesquet whose thesis deals with education at birth from the 19th century to the Nasser period tells us, it never really trained midwives as is understood in the French system. “Called ‘hakimat’, these midwives were supervisors who were in charge of traditional birth attendants. They were trained in first aid and hygiene but were mainly employed to liaise with the administration, especially for civil status.”
In this landscape dominated by a quest for profit, a parallel movement is emerging, particularly thanks to the hard work of gynecologists and obstetricians, represented by Doctor Hanaa Abo Kassem, who is campaigning to restore trust in women and remind them of the capacities of their bodies, especially thanks to hormones that play an essential role in natural childbirth, while the body goes through a trauma in the case of a caesarean section.
In her clinic Mum’s Haven established in Alexandria in 2016, Doctor Hanaa Abo Kassem offers all kinds of pre and postnatal services and has set up a team of doulas [3] to advise mums-to-be. The establishment is frequented by many expatriates but also by Egyptian women from upper middle and educated social classes, concerned about the benefits of a natural birth and tailor-made solutions, particularly childbirth in water or in the position of their choice.
Although still minimal at the country level and of the million annual births, this return to natural birth is increasing slowly but surely in a society where women are increasingly getting information and intend to improve their quality of life by giving priority to a “healthy” lifestyle.
Like the “This is Mother Being” initiative launched by doula and sexual health educator Nour Emam, which has 289,000 subscribers on Instagram, social networks reflect this trend. In Arabic and English, the latter advocates natural birth but also addresses topics such as menstruation, female pleasure, sexually transmitted diseases, and sexuality in general. A reason to hope for the future of Dalila and the Egyptian women in the path to reclaim their bodies and the way they wish to give life.
[1] Trop et pas assez à la fois : le double fardeau de la césarienne
[2] Names were changed to the request of the person interviewed.
[3] A doula is a birth attendant who provides emotional and physical support to the pregnant woman throughout her pregnancy and also after childbirth.