By Sarah Jamal
Everything is chosen carefully: a small bed, bottles and a silky hairbrush. Pink clothes for the day of delivery and a white dress for the week’s party have also been selected. Baby Massa was the only one left behind in hospital, undressed and confined to a glass box incubator so she could breathe.
Massa spent seven days with her limbs attached to medical devices through wires and with a tube going through her nose immediately after her birth. The newborn baby girl was transferred from the ventilator to the nasal oxygen cannula device, then to the incubator for more oxygen.
An x-ray of her heart was carried out, and she had to undergo daily examinations and analyses. She had to receive injections and intensive doses of medicines until she was able to breathe naturally on her own.
Massa and her mother, Aliyya, were “victims” of an unnecessary Caesarean section. One of the most prominent consequences of this procedure is the inability of newborns to breathe spontaneously, and some need to be put in incubators, which entails great health risks and financial costs.
This investigation is based on a questionnaire designed specifically to discover the reasons behind the unjustified rise in the rate of Caesarean sections operations carried out in Egyptian hospitals. The investigator discovered that eight out of ten women were subjected to such procedures between 2014 and 2020 based on responses collected from 6500 women. The period in question was not covered by any official health surveys.
The findings of this investigation have noticed a considerable increase compared to the last available official health survey collected in 2014 showing that five out of every ten pregnant women had to undergo a C-section operation to deliver their newborn,
According to the World Health Organization WHO, Egypt ranks fourth in the world in the table of highest number of C-section operations carried out. The questionnaire also shows that half the number of children born via Caesarean section suffered from complications after birth, and one in five children needed an incubator, while one in five mothers experienced health complications.
Aliyya did not want to undergo a Caesarean section; she had planned for a natural birth that she knew would be best for her and for her baby, especially since her pregnancy was stable and the fetus’s position in the pelvis was favorable. Unlike the case with other women, labor pains did not scare her as much as the idea of having her abdomen opened.
The doctor, though, seems to have had other plans. Aliyya remembers how terrified she was when her doctor told her, “If you do not give birth by a Caesarean section, you will be responsible for the safety of the baby. If she dies, we will open your abdomen anyway to get the baby out.”
The doctor did not mention any medical reason for Aliyya to give birth by a Caesarean section, although two weeks remained until her baby was due and despite previous assurances by the same doctor that her child was in a natural birth position.
Who decides on the Caesarean section?
Massa was unable to breathe normally from the minute she was born, and her body turned blue. The situation was critical, and the little girl needed an incubator immediately. She was slightly better off than 25% of the children whose mothers participated in the questionnaire and who faced difficulties in finding incubators. Her family did not need to resort to searching for incubators or to wait for long hours while the baby’s life was at risk.
They opted for an incubator in the private hospital where Massa was born, even if the cost was beyond their means.
The cost of incubators vary depending on the entity that provides them; some charitable health organizations provide these either for free or at a low cost. Incubators provided by the public health service are the least expensive after the ones provided through charity, but they are also the most difficult to come by when you need one.
This forced the families of four out of every five newborns to resort to source incubators from private sector providers for a high cost.
In February 2020, Fayez Barakat, Member of Parliament, submitted a request for a briefing to the Minister of Health. He demanded that unnecessary Caesarean sections be controlled, as these were the reason for the shortages in incubators. He also called for a legislative amendment that commits doctors to write a medical report explaining why they must resort to a Caesarean section to be reviewed by a specialized panel before the surgery.
Barakat stressed that the increase in the rates of Caesarean births is matched by an increase in the need for incubators, especially that a large percentage of Caesarean sections are performed at an earlier date than the due date. Then, the family’s journey of suffering begins as they search for available incubators, given their scarcity in the public health service, and the high cost of renting one from private providers or hospitals.
Dr. Rabab Ali, a specialist in pediatrics and neonatology, says, “A natural delivery helps to strengthen the fetus’s heart and activates its lungs to enable it to exit the womb and to breathe normally, which is a stimulus that Caesarean deliveries do not trigger.” She stresses that “babies delivered through Caesarean sections are more prone to respiratory problems and more likely to need incubators.”
Dr. Ali is alarmed by the method of transferring newborns from clinics and hospitals to incubators; she says, “Transferring babies without appropriate medical equipment may expose them to shortage of oxygen that may cause cardiac complications. This, in turn, may lead to mental and motor disabilities or convulsions.” She pointed out that the worst cases required access to incubators where she works were usually transferred from private clinics and hospitals that do not have incubators.
After an exhausting journey, Massa made it to her pink bed at her parents’ house. Her tiny body was colored with bruises and blood pooling in the spots where she was injected for samples and analyses. The incubator charges reached 1100 Egyptian Pounds, that is around $70 per night, in addition to the cost of medicines, tests and x-rays.
How much does the surgery cost?
The Ministry of Health has acknowledged that there is a huge increase in Caesarean sections operations and recognized the risks these pose to the health of mothers and newborns based on a study published in 2018, “Caesarean Sections in Egypt: Trends, Practices, Perceptions and Cost” that was conducted with the participation of the Egyptian Ministry of Health, the Population Council, the World Health Organization and the United Nations Population Fund.
A study published in the Egyptian Journal of Hospital Medicine tracked births at Banha Teaching Hospital: These amounted to 1500 cases in six months of 2018, 65% of the births were through Caesarean sections. Twenty percent of those born by a Caesarean section had complications that required placing them in incubators, and half of them had respiratory distress.
This was followed by meconium aspiration; meconium is the first stool produced by an infant and consists of materials that were digested when the baby was still in its mother’s womb. Other cases included sepsis and neonatal jaundice. Newborns stayed in incubators between three hours and twelve days, and ten deaths were recorded.
Marwa has had an open scar for seven months.
Marwa Maher also had a bitter experience with a Caesarean section: She says, “It was the worst experience of my life. My baby is now seven months old, and my post C-section cut is still open.”
The doctor who was following up on her case would confirm to her that she had a great chance at a natural birth, and she prepared herself for that. Later, she had to follow up with another doctor who insisted on delivering the baby by a Caesarean section in the 36th week of her pregnancy without medical justification.
Marwa suffered from a severe hemorrhage that lasted for more than fifty days, which led to a deficiency in red blood cells and to anemia. This is in addition to problems with bowel movement that prevented her from passing stool for twenty days, which led to initial poisoning. Her wound also remained open and inflamed, oozing pus, and it is still under treatment.
According to the study published in the Egyptian Journal of Hospital Medicine, 19% of mothers who delivered through a Caesarean section experienced complications during delivery. Most notable of these is a wounded uterine artery in 10% of the cases, followed by hemorrhage, adhesions, hysterectomies, and wounded bladders or intestines.
Ten percent also experienced complications after childbirth, with fever being the most common, followed by cuts and bleeding.
Marwa says, “At the beginning of my pregnancy, I searched a lot for a doctor who would not perform a Caesarean section without a valid reason, and more than one doctor would say they did not have time for a natural birth.” She continues, “My doctor refused to attempt a natural delivery despite my request and decided on a Caesarean procedure.
All those who gave birth when I delivered and until I was discharged from the hospital did so by a Caesarean section.” The Health Survey indicates that out of every ten women who gave birth in a private hospital, seven of them were delivered by a Caesarean section.
Although there has been a marked increase in Caesarean section deliveries in public hospitals, the study by the Egyptian Population Council describes the increase in private hospitals as “the most dramatic.” It notes that the unnecessary Caesarean sections are an added financial burden on women, their families and to the health system. In 2014, Cesarean deliveries cost more than 900 million Egyptian Pounds.
Forty-five percent of the doctors participating in the study said they would prefer a Cesarean section because it gives them better control over their time.
Marwa was unable to celebrate the arrival of her firstborn, and the burden of taking care of her and her little one fell on her mother and husband for more than a month and a half. Then, she had to quit her job due to her health condition. Marwa believes that doctors choose the Caesarean procedure for the profit factor.
Her delivery cost ten thousand Egyptian Pounds instead of the four thousand in the case of a natural birth. She says, “The cost of a Cesarean section is more than double the cost of natural delivery. The doctor’s job ends within a quarter of an hour instead of waiting for a whole day for one case.”
In a recent study published in June of this year, the World Health Organization indicated that the rates of Caesarean sections continue to rise globally, and they now represent 21% of all births in the world. It is expected that this percentage will rise to 29% by 2030.
Bleeding and cuts as side-effects
Thirty-year old Shaima’a had a 4D scan prior to giving birth, and the radiologist confirmed that the fetus was in a natural birth position. When she returned to her doctor, she informed Shaima’a that she would have her delivered by a Caesarean section and that the fetus was not in a natural birth position.
The doctor’s decision came in response to the mother’s fear of labor pain, and she is one of 16% of mothers who participated in the questionnaire who gave birth by a Caesarean section by choice. Despite that, Shaima’a informed her doctor that she was willing to give birth naturally if it was better for her and her child.
When the effect of the twilight anesthesia disappeared, severe pain gripped Shaima’a, but she was mostly hurting due to the incision across the head of her child Adam. She says, “The scalpel wound extended from his right ear to his left ear, and his mouth was bleeding. The situation was terrifying, and they ruined my joy over my son’s birth.”
Shaima’a was left without medical follow-up after the birth, and she had to pay one of the nurses so she would give her a sedative to relieve the severe pain. Her leg swelled up the day after the delivery, and the doctor told her that that was one of the complications of twilight anesthesia.
The study by the Population Council revealed that only six out of a hundred women are told about the risks of a Cesarean delivery, and this highlights the lack of informed consent. The study adds, “The women’s accounts showed a blatant lack of knowledge about the risks of a Cesarean delivery. When asked whether doctors provided women with information about the health risks and disadvantages of a Cesarean delivery, the women reported that the doctors refrained from informing them about it.”
The pediatrician told Shaima’a’s family that the baby was in a natural birth position, and so he grazed his head during the Caesarean section. He reassured them that the wound was superficial and that it would heal with time, and he prescribed a treatment for his bleeding mouth.
Adam did indeed recover after two years. Shaima’a believes that her doctor should have directed her to what was best for her and her baby and that the decision to deliver the baby by a Caesarean section was for financial gain. There was no medical justification for the procedure, and it caused unjustifiable psychological and physical harm to her and to her baby.
Nada went natural after her first C-section
Twenty-nine-years-old Nada describes her experience with her first Caesarean section as “shocking,” especially that she was directed by more than one private doctor to deliver by a Caesarean section unnecessarily. This forced her to change her primary care doctor more than once.
Most of the respondents in the study by the Population Council said that they monitor their pregnancies in private clinics and hospitals because they believe that private doctors are more experienced and have modern equipment, such as ultrasounds.
They also provide more information and are more attentive to their concerns and needs. When asked about the birth advice they were receiving, the women mostly agreed that doctors in public health hospitals would encourage them to have a natural, vaginal delivery while most doctors in the private sector prefer a Cesarean section.
As her due date was approaching, Nada was again directed to give birth during the 37th week, which she refused and insisted on completing her pregnancy. Nada says, “Selecting the date of the Caesarean section to suite the doctor’s schedule and not the medical condition of the mother is an unnecessary risk.” Eventually, Nada had to give birth by a Caesarean section, but at least it was not at a very early stage.
Pediatrician Rabab Ali stresses that the biggest problem with an unnecessary Cesarean delivery is that some doctors set an early date for the birth at 37 or 38 weeks or earlier without medical need. This increases the unnecessary risk of the mother and baby experiencing health problems. A first-time mom can wait until week 42 as long as her pregnancy is stable.
Dr Ali highlights that children born through a Caesarean section in the first weeks of the ninth month are also more likely to develop physiological jaundice due to the incomplete development of the liver. The uterine age of the child, that is the number of weeks of pregnancy and the fetus’s weight are important factors in determining whether or not a baby with jaundice would need an incubator.
Nada gave birth to her second child naturally after her first was born through Caesarean section delivery, but until the ninth month of pregnancy she faced difficulty in finding a doctor who would agree to have her delivered naturally. She also had to hide her wishes from her family and friends to avoid social pressure.
Indeed, people around Nada were surprised, for it is believed that if a woman gave birth by Caesarean once, she would have to deliver all her children by a Caesarean section. This prompted Nada to launch a page called “Go Natural After a Caesarean Section” on Facebook, YouTube and Instagram to educate mothers about the advantages of natural childbirth and the possibility of its occurrence after a Cesarean section.
Former Member of Parliament Fayez Barakat holds the Ministry of Health and the Egyptian Medical Syndicate responsible for the escalation of unjustified Caesarean sections newborn deliveries, and for the risks to which mothers and children are exposed since these are the two entities that should monitor the work of doctors. He noted that some doctors rush to perform a Cesarean section for profit purposes. As for his parliamentary request to commit doctors to writing a medical report to be submitted to a specialized panel before performing a Caesarean section, he says that, “Nothing has happened.”
The investigator repeatedly tried to communicate with the spokesperson at the Ministry of Health, Dr. Khaled Mujahed and then with Tariq Tawfiq, the Deputy Minister of Health for Population Affairs, but to no avail.
When she went to the Medical Syndicate to follow up on its procedures with doctors who perform medically unjustified Caesarean sections, Dr. Osama Abdel Hay, Secretary-General of the Syndicate and head of the Professional Ethics Committee, answered her, “No citizen has filed a complaint with the Syndicate because of medically unjustified Caesarean sections.” He blamed the women themselves and said, “It is a tragedy because sometimes women themselves request a Caesarean section.”
Abdel Hay was asked about the doctors’ responsibility to submit a medical report to explain the reason for resorting to a Caesarean section and presenting it to a specialized committee before the surgery and about the demand for a legislative amendment his response was, “The report on the Caesarean section should already be included in the patient’s file, but I am not sure of the rules followed in the women’s departments.”
Adam has recovered from his head wound, and Massa’s mother is working hard to remove the burn-like effects of injections from her daughter’s skin. Nada is calling on pregnant women to give birth naturally after a Cesarean section, and Marwa tries to treat the open wound left as a result of her Caesarean section. In the meantime, a medically unexplained Caesarean scalpel continues to hang over the bellies of hundreds of thousands of mothers and newborns annually.
This investigation was conducted with the support of Arab Reporters for Investigative Journalism Network (ARIJ).
The views expressed in this article do not necessarily reflect those of Al Bawaba News.
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