18 April 2014, Friday
Today's Zaman

Turkey's new epidemic, C-sections: A cut above?

21 September 2008, Sunday /FAZİLE ZAHİR / FATMA DİŞLİ
Turkey is suffering from an epidemic that seems to be spiraling out of control. Like many developing countries, as the level of wealth and standards of education have increased, there has been a concomitant reluctance to give birth naturally and a staggering rise in the number of Caesarean section births.

According to Health Ministry data, 288,000 of the total 706,000 births in Turkey were through C-section operations in 2006, while 251,000 of the 766,000 births in 2007 were C-sections.

The first recorded Caesarean section in Turkey was in 1879, when after 36 hours in labor a mother cut her own belly and uterus open with a razor. The wound was sewn up by a neighbor, and both mother and infant survived. Since then C-sections have become more and more common. In the late 1980s 92 percent of women had natural births; by the mid-1990s this figure had dropped to 81 percent; and in 2004 normal births constituted 79 percent.

But the last four years have seen an explosion in the figures, and last year only 51 percent of women gave birth naturally. It seems that Turkish women have become either too scared or too posh to push.

The World Health Organization (WHO) has a recommended an upper limit for medically justified C-section births of around 15 percent in any country, and Turkey's current level is more than double this. The figures are even more astounding if looked at on a geographical, educational or financial basis. The highest levels in 2008 are in the more affluent and urbanized western and northern parts of Turkey -- 48.1 percent on the Black Sea coast, 47.2 percent on the Aegean coast and 42.9 percent around the Sea of Marmara. Afyonkarahisar has an absolute record figure of 64.8 percent of all births being Caesarean sections, and affluent İzmir has nearly half, 45.3 percent. Eastern Turkey, the relatively poorer part of the country, is still above the WHO recommendations but has the lowest national percentile, only 23.9 percent, followed by southeastern Anatolia at 26.1 percent. Out of the towns in this area, Ağrı in 2008 has recorded only 10.1 percent of births as C-sections and Diyarbakır 14.5 percent. The better educated you are in Turkey, the more likely you are to have a C-section despite being bright enough to absorb and analyze the information that makes it clear that natural birth is better for mother, child and the national economy.

Expensive and costly

The growth in C-section births is a worrying trend for the government as it indicates that Turkey is headed towards a more costly medical system it can ill afford, and there have been various moves made by the current government to try to reverse the trend. In mid-April of this year the Ministry of Health changed state doctors' wages to favor those who participated in natural births and reduced the performance pay for doctors with high levels of Caesarean operations. Previously the state had paid government hospital doctors YTL 742 for a C-section but only YTL 277 for a natural birth. Under the new ruling natural births have begun to be paid around YTL 410 and Caesareans less.

The ruling had an immediate effect, and levels of C-section births have fallen from a high of nearly 41 percent last year to 32 percent so far this year.

According to the Health Ministry's "Performance and Quality Directive in the Health Sector," which went into effect on Sept. 1, the number of C-sections performed at hospitals will be a criterion for assessing the hospital's overall performance. In line with this, C-sections at teaching hospitals may not exceed 20 percent of all births, while this is to be 15 percent for other hospitals.

Hasan Güler, a Ministry of Health official with responsibility for drawing up the guidelines under which hospitals and clinics are rated, said; "As a ministry we want to bring rates down to WHO-recommended levels, and to that effect we have set targets that all hospitals should perform no more than 15 percent of all births at that hospital by Caesarean section and that all teaching hospitals should not exceed 20 percent. Our changing the rating criteria drew attention to the issue, and people began to question the number of Caesareans taking place. We've started the process to reduce the numbers, and this trend will change slowly." Just this week Health Minister Recep Akdağ was gunning for obstetricians again in a statement to the press which said: "If an obstetrician is performing 60 or 70 births out of 100 by Caesarean section, he needs us to train him. He obviously doesn't know how to deal with a natural birth." The doctors were quick to respond, and Professor Turgay Şener, head of the Turkish Perinatology Association, said; 'The WHO figure of 15 percent seems good, but it's not adhered to by developed countries. When we look outside of Turkey, the rates of Caesarean sections are rising there, too."

According to Professor Şener Caesareans have grown in number for four main reasons. Firstly he cites a lack of post-natal care, which means that doctors are faced with pregnant women with unknown, non-assessed risk factors although he does allow for the fact that the Ministry of Health is doing work to improve this situation. Secondly, he claims a lack of trained nurses means that they cannot allow the amount of time needed for a natural birth and that pregnant women have not had training by qualified midwives in what to expect during a birth. The third reason is a change in the type of pregnant women; they are generally older now, more averse to risk, more likely to have had IVF and be carrying twins or even triplets and also may have conditions that formerly would have prohibited pregnancy, such as diabetes or heart problems. The fourth reason, and perhaps the most revealing for the huge rise in C-sections over recent years, is fear of litigation. 'The most frequently sued type of doctor is an obstetrician, so if you don't have enough nurses, enough anesthetists, enough newborn infant specialists, you don't take any risks. The smallest mistake can lead to huge demands for compensation, so doctors avoid natural births." Thus Turkish doctors are making decisions based on fear of malpractice suits rather than on medical necessity.

Dr. Bülent Traş, head of the Turkish Gynecology and Obstetrics Association, objects strongly to the targets set by the ministry. "Natural births are not the province of doctors. ... They are part of the duties of midwives. Our responsibility is the safety of mother and child, and if we consider this to be at risk, we have the right and duty to perform a Caesarean. Because of the work of obstetricians, mortality in childbirth has fallen remarkably in recent years," he said.

According to Türk Sağlık-Sen (Turkish Healthcare Workers Union) Chairman Önder Kahveci it is wrong for the ministry to reduce the C-section rates through regulations. "First of all, a mother's choice is important. Secondly, if there is a risk for either the baby or the mother in natural birth, doctors inevitably resort to C-sections to avoid any complications."

Nevertheless, Kahveci acknowledges that if there is an abuse of these operations for the sake of earning more money, measures should be taken to prevent such cases.

What neither doctor mentions are the two main anecdotal reasons that doctors and mothers choose C-sections. Doctors enjoy the profits from a surgery for which some charge as much as YTL 8,000 and the speediness of the procedure. A skilled surgeon could perform 10 such operations in the same 24 hours when he might wait for a single woman to go through labor normally. Research conducted in 2004 by the Uludağ University medical faculty showed that 86 percent of births in private clinics were Caesareans. Dr. Kadriye Avcı, who took part in that research, was scathing in her assessment of the increase in the rate of C-sections. "The increase in rates of Caesareans is without doubt down to doctors thinking about their accounts and taking needless risks for their own gain. Their economic advantages are set over and above ethical issues." Avcı also believes mothers, who listed the baby's safety as their prime concern when asked, were deliberately under-informed about the risks of surgical intervention.

Doctors on defense

Leyla Erdem, a gynecologist at İstanbul's private Medical Park Hospital, finds the argument that suggests they advise C-section operations to mothers to earn more money to be very insulting to doctors. She says this approach indicates a lack of trust in doctors. "We do not perform C-sections unless there is a risk for the mother or the baby. As a result of increasing C-section operations, complications that emerge during natural births are avoided, and it is possible to say that the birth of spastic babies has declined," Erdem said.

She also finds it wrong for the ministry to try to reduce the rate of C-sections through regulations without providing the necessary equipment or staff at hospitals. Erdem suggests a more extensive approach, aimed at solving the basic problems in the health care sector, to deal with problems such as the rising C-section rates.

Mothers like the option of pain-free childbirth and the element of control that Caesareans give them. Certainly none of the reasons given by Professor Şener explain the huge demand by women worldwide to have their C-sections on Aug. 8 of this year, though the superstition that as an auspicious day certainly does.

Television shows that medical births often focus on problematic pregnancies where mother and child are heroically saved by a doctor's surgical skills and equipment and foster an environment in which surgical intervention looks like the norm. Birth stops being a normal physiological process and becomes something that resembles intensive care or an episode of "ER." Technology and terror become the overriding factors in an experience that women have in the past experienced on an intuitive basis; after all who does a first-time mum trust? Her body or the doctor with 10 years of training? There are other elements at play, too: For some mothers, pushing a baby out seems too messy, too painful and even too animalistic. The upper class women of Turkey with their trim bodies and sleek bobs can't abide the idea that they might lose their dignity, muss their hair or, heaven forbid, sweat. Turkish doctors seem intent on treating natural birth as a pathological medical condition, almost as a disease to be cured, and some women just won't consider catching it. 

Celebrity moms against C-sections

According to a news article published by the Radikal daily last week, celebrity mothers in Turkey think that C-sections should not be resorted to unless medically necessary.

Actress Nurgül Yeşilçay: Yeşilçay gave birth to a son, Osman Nejat, in 2005 through natural birth in water. She said she and her husband, actor Cem Özer, were waging a war against C-sections. "Do not be deceived by doctors. Do not give consent to a C-section. We demanded a natural birth, and Nurgül is very healthy now," Özer had said back then.

Photographer Bennu Gerede: Gerede, who gave birth to all her four children by natural birth, says mothers should avoid C-sections unless necessary. "A C-section is the last resort in the world. What is normal is natural birth," she said. Gerede says both mothers and doctors prefer the easy way in opting for C-sections. "Mothers fear their bodies becoming deformed when they give birth naturally, while doctors make more money in performing C sections. But it is not a healthy method." Model Sinem Güven: Güven gave birth to her daughter Defne in March 2008 in a natural birth. She strongly opposes C-sections when medically unnecessary. "From the start of my pregnancy, I was planning to deliver my baby naturally. I even bargained with my doctor. Doctors are performing C-sections with an appointment as if they are pulling a tooth. I can't understand this. To come into this world through natural birth is something that strengthens the immune system of the baby. Natural births also help mothers to heal quickly." 

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