BEIRUT: From the beginning of her pregnancy, Abir Mansour knew that she didn’t want a C-section. As the months passed and she grew closer to term, some tried to sway her otherwise with unsolicited advice, such as the woman who told her that a C-section wouldn’t be painful, nor would it upset her sex life like a vaginal delivery would.
Mansour maintained her resolve. “I wanted a normal birth. I didn’t want surgery,” said the mom, who gave birth to her first child, Anthony, last year.
Just three months from her due date, she learned that vaginal delivery would not be possible. Mansour’s doctor told her that a C-section was necessary, because of her baby’s weight and position. She had no choice but to undergo the procedure she had hoped to avoid.
Mansour is one of many women in Lebanon who have given birth through C-section, a surgical procedure of delivery that requires an incision through the abdominal wall and uterus.
In situations where the health of the mother or baby would be jeopardized by vaginal birth, C-sections have saved lives. However, an increasing number of women worldwide are giving birth via C-section for nonmedical reasons, and Lebanon is no exception. This trend has maternal health practitioners concerned.
Like other countries worldwide, Lebanon has seen C-section rates increase as the process of giving birth has become more medicalized, and populations have experienced demographic shifts such as rapid urbanization. In a 2010 study that gathered information on maternal health in Lebanon, data reported from hospitals across the country revealed a C-section rate of 40.8 percent, far above the World Health Organization’s (WHO) recommended rate of 15 percent.
If a country’s rate falls far below that 15 percent level, it’s a sign that women aren’t getting access to C-sections that may be medically necessary. However, a rate far above the WHO’s recommendation is an indicator that there may be a high number of C-sections performed for nonmedical reasons.
For most of human history, babies have entered the world through the birth canal, or not at all. The majority of births still happen this way, but the advent of C-sections gave doctors an alternative means of delivery where a natural birth would be unsafe. Nonetheless, maternal health researchers have reported that, as a surgical procedure, C-sections carry more risks.
Caroline Osman, an OB-GYN based in Downtown Beirut, said she encourages her patients toward vaginal birth. “While C-sections are improving, with smaller incisions, it is still a surgery,” she said, explaining that there are higher chances of complications and infections, as well as maternal and infant mortality. Moreover, C-sections require longer hospital stays and recovery time.
Tamar Kabakian, an associate professor in the Department of Health Promotion and Community Health at the American University of Beirut, has studied the rise of C-sections, and the causes of increased prevalence.
She said that the procedure is directly marketed at women as a safe method of painless delivery, and as a way to avoid labor. “It is presented by providers as a way out,” she said, adding, “we are a culture where women are not highly empowered to own the pain that comes with labor. We always try to avoid pain.”
In her 2013 study exploring Lebanese women’s experiences of C-section delivery, Kabakian found that health care providers weren’t giving women enough information on the realities of the procedure and associated recovery pain. Consequently, women weren’t able to make the most knowledgeable delivery choices.
Through her research, Kabakian has also found that misconceptions surround pain relief procedures for vaginal childbirth. For example, some women hold the belief that an epidural injection will cause paralysis. This fear can steer women away from a vaginal delivery.
Kabakian said that the organization of Lebanon’s predominantly private health care system is a key factor shaping the choices of women and doctors.
“We don’t have accountability within the private system,” she said, explaining that there aren’t national policies that regulate practices of all hospitals in birth interventions.
At the system level, she said that OB-GYN practices in Lebanon are typically characterized by direct patient-provider relationships as opposed to group practices that would accommodate the unpredictable nature of natural childbirth.
“It is more convenient to schedule things around with a C-section, because they don’t have anyone else to cover absences if the provider needs to be somewhere else,” Kabakian explained.
As a remedy, she encouraged the growth of more group obstetrician practices. In her 2007 study, Kabakian also recommended the implementation of national-level guidelines for maternal health practice, as well as awareness campaigns to better inform women.
Caroline Osman, a Beirut-based OB-GYN, has seen a rise in demand for medically unnecessary C-sections since she began her practice in 2005. Like Kabakian, she said that many women want to avoid the pain of labor.
They also fear vaginal tearing and the possibility of needing an episiotomy, a small incision in the perineum that eases the baby’s passage.
Other reasons are more cosmetic in nature.
“Some women prefer to maintain their antenatal region. For their sex life,” Osman explained. While many of her clients choose vaginal delivery, she said, “an increasing number of these women want vaginal reconstruction surgery.”
Prenatal yoga teacher, Dunia Abou Jaoude, advocated for a shift in how women experience childbirth. She offers yoga lessons to expectant mothers, as well as sessions on hypnobirthing, a nonmedical method of pain management that she said teaches the mother to mitigate anxiety during labor.
Abou Jaoude suggests that women with no pregnancy complications give birth at home in a calm, comfortable environment, free from strangers and interruptions. While most who attend her sessions want some form of pain relief to ease labor pains, for instance, an epidural, she advises her students to know their options and keep them open. That way, they can make informed decisions about delivery.
“You might find it easier when you know what to do with your body, and how your partner can help you,” Abou Jaoude said.
As labor has become more medicalized, so have unnatural birthing positions that confine women to beds. Abou Jaoude advocated a return to more natural positions.
“The best way to prevent tearing is to be off your back and off your butt,” she said.
As for fears surrounding vaginal elasticity, Abou Jaoude said that pelvic muscle training can help fight loosening. The mother can practice these exercises with a specialist, before and after birth to strengthen pelvic muscles.
Kabakian, the AUB professor, also said that the typical birthing environment presents a major challenge for vaginal delivery. While interventions should be available to the mother should complications arise, they should not immediately reach for, if not necessary.
She said, “in an ideal environment, she would not be treated as a patient because [giving birth] is not a disease.”
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