Wednesday, December 10, 2008

Shocking cesarean controversy in Turkey

In a December 2nd article on Today's Zaman website, reporter Ayse Karabat writes about a shocking policy on cesarean delivery in Turkey, and one that disturbingly echoes some of the calls for cesarean delivery restriction in countries like the UK, U.S. and Australia.

The report says that Turkey's Ministry of Health wants to reduce its cesarean rate from 42.5% to 25% by restricting cesarean deliveries only to those who medically need them.

In a statement issued this year, it declared that from Sept. 1, the number of cesareans at a health institution "will be taken into consideration when calculating the performance of hospitals. Pursuant to this statement, [cesareans] should be no more that 20% of all births in research and training hospitals and no more than 15% for other hospitals. If the [cesareans] in a hospital are higher than these levels, hospital funding and staff pay will be cut."

You may remember our press release back in October 2008, when the Coalition for Childbirth Autonomy warned of the dangers of forcibly or artificially reducing a nation's cesarean rate to the outdated level recommended by WHO in 1985. Well, perhaps the shocking practices now taking place in Turkey might be a lesson to other government health strategists:

Comments by doctors working in the obstetric field highlight many of the points I have made in the past about the repercussions of reducing cesarean deliveries simply in order to achieve a 'magic number' - rather than making the best decision in each individual case.

Avoidable mortality and morbidity with PVD costs more than CS
*The news report states that "
since the implementation of this program, doctors have been discussing the subject. Some are claiming that the money which is being spent to deal with complications resulting from normal births is higher than the expenditure" for cesarean deliveries.
Critical health care decisions belong in the room the birth takes place
octors are critical of the program from the Ministry of Health, claiming that decisions regarding [cesareans] can be taken only by doctors and to question it is unethical."
Litigation pressure and costs should not be ignored or underestimated
"Professor Turgay Şener, the chairman of the Turkish Perinatology Association, has said any directions from the Ministry of Health will not be useful in reducing the amount of [cesareans]. "Restrictions can lead to disagreements between doctors and patients. If there is even a small problem, the patient will ask the question if it was because of the normal birth."
Enhanced health outcomes are missed when a valid delivery route is avoided
"The doctors will feel pressured and will choose normal births in some cases where cesarean sections are better," [Professor Şener] underlined.
Financial reward (or fear of financial loss) influences doctors' decisions
*"Turkish Gynecology and Obstetric Association Chairman Bülent Tıraş has suggested that the number of [cesareans] will affect the performance of the whole of the hospital and have an impact on other doctors' pay, so this may put pressure on gynecologists to choose normal births."

Does all this really help women and their babies?
No, of course not. It's interesting to read though, that Turkey's strategy uses the
slogan: "Every pregnant woman should be given the chance to give birth naturally." I think it would make a lot more sense, save a lot more lives, and avoid a lot more birth injuries if Turkey altered its slogan to this one:

"Every pregnant woman should be given the chance to give birth in the way she chooses to."

And if the woman doesn't have a particular choice one way or the other (some don't), then it should be a case of providing the best possible health care on the day of the birth, regardless of how that birth outcome might affect a table of statistics on a desk somewhere in the hospital.


Anonymous said...

Your proposed slogan is laughable.

c-sections are 3x's more deadly for women than natural birth.

have more post-operative risks blood clots, infections, loss of fertility either because a hysterectomy was needed, or because scar tissue makes future pregnancy impossible/unlikely, or by choice., increased risk in future pregnancies (including uterine rupture with or without labor) AFE's are also more common with cesarean deliveries which are almost always deadly.

If women were given FULL informed consent about what happens and could happen during/following a c-section instead of the dumbed down version that she is handed, or maybe not even given at all (happened to me 2x's...after my first c-section I was given the Informed consent AFTER surgery and it wasn't even an emergent c-section! The second time A paper was shoved under my nose and I was told to sign it...again not an emergent c-section.

In a country where Large families are the norm, preventing unnecessary c-sections is prudent.

cesarean debate said...

Anonymous: The '3x more deadly' risk that you mention (and indeed the others below it) are associated with emergency and medical cesarean deliveries. This figure is not applicable to planned cesarean deliveries in healthy pregnancies.

I'm sorry that you had such negative birth experiences, and not knowing the circumstances of your surgeries, I cannot comment on them specifically.

What I do know however, is that (understandably) women who have 'unwanted' cesarean deliveries are far less satisfied with the birth outcome than women who have 'wanted' cesarean deliveries.

You need to appreciate that just because you were unhappy with a cesarean delivery, this is not the case for all women. You also need to better understand that many of the cesarean risks you mention in your post are actually more likely with an emergency cesarean (the majority of which occur as an outcome of a planned vaginal delivery) and should therefore be explained to women planning vaginal deliveries too.

With regard to your comment about large families; you are correct in that the risks associated with (any) cesarean surgery have been shown to increase with number. However, again, as I always state, cesarean delivery with no medical indication is only advised for women planning small families.

Anonymous said...

The Risk associated with cesarean delivery does NOT change if it is a planned or unplanned surgery.

SURGERY is SURGERY no matter what.

One cannot know in advance how a woman will heal from surgery, or how much scar tissue (adhesions) her body will produce.

A woman who only planned to have 2 children, may find herself wanting more 5 or 10 yrs down the road, perhaps she remarries, or just has a change of heart.

Our childbirth decisions NOW may effect us in ways we would have never imagined down the road.

cesarean debate said...

Anonymous: I'm afraid you are entirely incorrect in your statement that the 'risk associated with cesarean delivery does NOT change if it is a planned or unplanned surgery.' If you read any medical study or national health guidelines comparing the two, you will find that emergency cesareans are indeed associated with far greater risks than planned surgery.

As for your comments regarding the repercussions on a woman's long-term reproductive future, yes, a woman must think carefully about how many children she plans to have, and yes, there would be increased risks for a 3rd or 4th unplanned surgery. However, if you look at average fertility rates in the developed world (the majority are <2), you will see that this applies in the minority of cases.

Also, you need to appreciate that a woman can never know how her body will respond to vaginal delivery either. She may end up needing instrumental assistance, she may suffer a 3rd or 4th degree tear, she may need surgical repair to her pelvic floor in the short- and/or long-term, she may become incontinent as a result of perineal damage. Similarly, her baby may become stuck during the birth process with severe morbidity occurring as a result.

I don't say all this to paint a negative picture of vaginal delivery - I say it to counter your perspective that the worst outcomes always occur with surgical births.

But you are right about one thing: our childbirth decisions now may affect us in ways we would never have imagined down the road. What I would add is that it should therefore be up to each individual woman to decide which set of risk and benefit repercussions she finds most tolerable during her own personal journey down that road.

Anonymous said...

From my understanding...previous to this decision in Turkey, women did not have a choice of VBAC. So if anything this decision is giving women the option to make up their minds.

You're for women being able to choose unnecessary c-sections for whatever reason. However there are HUNDREDS of hospitals in the US (thousands perhaps millions in the world) right now, not allowing women the option of vaginal birth after a prior c-section. Where is your voice arguing for them? I'd say finding an OB (especially of the younger generation) willing to perform an unnecessary c-section is much easier than finding one who will allow a woman a tol after a c-section...and 100x's easier than finding an OB who would allow a TOL after multiple c-sections.

Vaginal birth in and of itself is no more damaging to the pelvic floor than NEVER having children (I'm sure you're heard of the NUN study, which found similar rates of incontinence among Nun's and women who either had vaginal birth or cesareans) The fear of pelvic floor damage is a valid one sure, but the long term consequences that you describe are rare.

Shoulder distocia (Getting "stuck") occurs rarely and can be dealt with quickly and without major morbidity to either Mother or Baby, position changes, turning off the pitocin (not using it at all! Shoulder Distocia increases with the use of Pitocin) Reducing the use of instuments (pulling baby down too far before he is able to rotate = Sticky Shoulders)

Cesareans can't prevent problems with the baby, they can't garantee a healthy baby. My 2nd c-section I was coerced into for fear of a shoulder distocia (large baby) It was "Planned" in that I was guilted into agreeing to it 24hours before it occured. My Son suffered a Hypoxic Brain Injury, he was removed from my at 38wks 1day He was damaged due to an unnecessary surgery.

Fear is not a valid reason for major surgery used to avoid a natural process. Surgery should be used as a life saving last resort.

My Opinion.

cesarean debate said...

Anonymous: Firstly, I think that the decision to have a VBAC (while it wouldn't be my choice) is that of each individual woman and her doctor. I have never stated that VBAC should not be included in the spectrum of childbirth choices, but I feel that there are other birth groups that already support and give a voice to women making this decision.

Re: the study on nuns that you refer to, I have already posted about this, and will copy and paste it again here:

There are two studies on nuns that I am aware of, one in 2002 ( and the other in 2005 (
You can read the details via the links, but the important points to note are these:

1) The studies only measure prevalence of urinary incontinence. They did not ask the women about any problems with fecal incontinence or pelvic organ prolapse for example.

2) Most importantly. The women questioned were of a very mature age. They are described as having a 'mean age of 68' in one study and 'postmenopausal' in the other. It is well established that the incidence of urinary incontinence generally increases with age, regardless of parity. The question researchers need to ask is whether vaginal delivery is associated with an increased prevalence in women of childbearing age (e.g. the age groups 20,30 and 40 years-old), at a time in their lives when incontinence is NOT to be expected. There are nuns of this age available for questioning and I think that the results of this type of research would be more appropriate.

Shoulder dystocia is occurring more rarely partly due to the increase in elective cesarean deliveries. Modern women are delivering larger and larger babies, and if you read any studies on macrosomia you will learn that the morbidity risk is much greater for these babies, so some women and their doctors make the decision to plan a cesarean in preference to a trial of labor when macrosomia is suspected.

I am sorry that you had a negative birth experience, but in fairness, no delivery method in the world (natural or surgical) can guarantee a healthy baby. That said, I must disagree with you that cesareans can't prevent problems occurring with a baby. On the contrary, medical studies demonstrate otherwise.

Your last point - regarding cesarean delivery being used only as a life-saving last resort - is disappointing from a women whose opening remarks referred to the issue of choice (with VBAC). As I'm sure you are aware, there are documented risks associated with a VBAC. So if you support women who make the decision to choose this set of risks over those associated with a repeat cesarean, how can you be a true advocate of choice if you refuse to accept a healthy woman's decision to choose the risks associated with a planned cesarean delivery over those of a planned vaginal delivery?

Anonymous said...

The Point I was making was that prior to this decision in Turkey women did not have any options other than repeat c-section. So instead of saying "but they should have a choice to have a c-section if they want one" Perhaps you could say "Hey Now they have childbirth options" I doubt any Dr. is going to force a woman to have a vaginal delivery if she doesn't want one. But every women who WANTS a vaginal delivery should be able to try..

You're right, no birth options hold any garantees. BUT the prevailing thought process is that vaginal birth is risky, cesareans are life saving. And that's just not the case. Cesareans are major surgery with all of the risks of major surgery for the mother, and many risks for the newborn as well. The Maternal death rate is rising, it's higher than it's been in over 30 years. The March of Dimes has come out against c-sections and inductions planned prior to 39wks without medical cause because of the high rate of inadvertant prematurity. There are very real risks associated with prophylactic c-section. If the surgery is not medically necessary it should not be performed.

As for the risk of VBAC, yes there are risks, yes bad things happen. But more times than not, the first c-section was probably unnecessary or preventable had a Dr. simply waited for the natural course of the pregnancy rather than inducing early, or ordering that prophylactic c-section because the DOCTOR is worried about his malpractice rates going up if anything should happen. This is NOT evidence based medicine...its a travesty.

If you chose to put yourself and your child at higher risk out of fear...that's fine. But being appalled that women in Turkey now HAVE a choice...that's sad.

cesarean debate said...

Anonymous: If indeed what you say about Turkey prior to this policy is true, and women were not having their decision to deliver babies vaginally respected, then this is also not an ideal situation. However, two wrongs don't make a right. What you're effectively saying is that it's an acceptable situation now that some women are not being allowed to have their preferred cesarean delivery - as though their desired birth plans are somehow less valid than the women who share your own personal delivery preference. Surely the situation will only be fully resolved once ALL pregnant women have a choice?

Incidentally, I also share the concerns of some of the doctors quoted in the article, who worry that even cesarean deliveries needed for medical reasons may be underused, potentially leading to avoidable cases of mortality and morbidity.

You mention that the March of Dimes is critical of cesareans performed prior to 39 weeks, and then complete that paragraph with the sentence, 'If the surgery is not medically necessary it should not be performed.' You are again mixing up your facts and understanding here. Time and time again, recommendations for planned cesarean delivery state the need to wait until 39 weeks EGA; this is nothing new. In fact, this is precisely what women planning non-medically cesareans are advised. So since this is the safest documented time for cesarean delivery, and if a woman and her doctor follow this recommendation, who are you to tell them that the delivery shouldn't be allowed?

On a final note, I would like to ask you whether you've ever read the multitude of birth stories documented by women on websites such as the UK's Birth Trauma Association or Birth Trauma Canada? Many of these women write that they would have preferred to have had an elective cesarean delivery or would definitely schedule one for their second pregnancy. I would also like to ask you whether you take notice of the regular stories of birth litigation being reported in the media? Situations where cesareans were not carried out in time or not carried out at all, and the attempted vaginal delivery resulted in death or injury to the baby or mother. Are you really 100% sure that waiting, and leaving everything in the hands of Mother Nature is what doctors should always do? Put yourself in a doctor's shoes for a moment - would you be the type of doctor to be extra cautious or would you be more comfortable sailing close to the wind when complications start to arise?

And yes, fear of litigation isn't an ideal hospital bed-side partner, but like it or not, it's every bit as much a reality as the birth itself. Tell me, how would you propose removing its presence from each baby's birth? Do women sign a waiver form promising not to sue if the cesarean they've made abundantly clear they DON'T WANT and DON'T NEED is not carried out - but then injury or death results and their lawyers make the case that the doctor in his/her professional capacity should have known better and taken charge when complications came to light?

As I'm sure you know, with any birth, things can deteriorate rapidly and decisions often need to be made very quickly. Some doctors (having had the experience of delivering hundreds and even thousands of babies) may see signs of potential complications long before an emergency arises, and they may counsel women to schedule a prophylactic cesarean surgery. If this is happening too often and with too much caution, then yes, perhaps the situation needs to be examined carefully, but to throw the baby out with the bath water helps no one.

So let's look at what's happening with VBAC choices; let's look at what's happening with elective cesareans prior to 39 weeks EGA. But don't penalize women who are making the personal and valid decision to have one or two babies delivered at confirmed 39 weeks EGA by cesarean delivery. They have nothing to do with the two issues above.