Oct 1, 2008
Are Turkey's women too posh to push?
By Fazile Zahir
FETHIYE, Turkey - Turkey is suffering from an epidemic that seems to out of
control. Like many developing countries, as the level of wealth and standards
of education increase there has been a reluctance to give birth naturally and,
consequently, a staggering rise in the number of Caesarean-section births.
The first recorded Caesarean, or C-section, in Turkey was in 1879. After 36
hours in labor, a Turkish 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 increasingly common.
In the late 1980s, 92% of women had natural births. By the mid-1990s this
figure had dropped to 81%, and in 2004, normal births constituted 79%. But the
past four years have seen an explosion in these figures and last year only 59%
of women were giving 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 upper limit for medically
justified C-section births of around 15% in any country - Turkey's current
level is more than double this. The figures are even more astounding if looked
at on a geographical, educational or monetary basis.
The highest levels of C-sections occur in more affluent and urbanized western
and northern parts of Turkey; 48.1% on the Black Sea coast, 47.2% on the Agegan
coast and 42.9% around the Sea of Marmara. Afyon city holds the record figure
at 64.8% of all births being Caesarean. Meanwhile, affluent Izmir had nearly
half at 45.3%.
Eastern Turkey, the relatively poorer part of the country, was still above the
WHO recommendations, but had the lowest national percentile at 23.9%. The
southeast's Anatolia was at 26.1%. Of the towns in this area, Agri recorded
10.1% of births as C-sections, and Diyarbakir 14.5%.
Better educated residents are more likely to have a C-sections, despite being
educated enough to absorb and analyze information that makes it clear that a
natural birth is better for mother, child and the national economy.
The growth in C-sections is a worrying trend for the government: it indicates
that Turkey is headed towards a more costly medical system it can ill afford.
There have been various moves made by the current administration to reverse the
In mid-April this year, the Ministry of Heath changed state doctor's wages to
favor those who participate in natural births and reduced the performance pay
for doctors with high levels of Caesarean operations. Previously the state had
paid government hospital doctors a budget of 742 lira (US$589) for a C-section,
but only 277 lira for a natural birth. Under the new ruling, natural births
will be awarded around 410 lira and Caesareans less.
The ruling has had an immediate effect and levels have fallen from a high of
nearly 41% last year, to 32% so far this year. Hasan Guler, a ministry of
health official tasked with 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% of births by Caesarean and all teaching
hospitals should not exceed 20%. 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 reducing the numbers and this is a
Just this week the Minister for Health, Akdag, was gunning for obstetricians
again. He told the press that: "If an obstetrician is performing 60 or 70
births out of one hundred by Caesarean section he needs us to train him. He
obviously doesn't know how to deal with a natural birth."
Doctors were quick to respond. Professor Sener, head of the Turkish Perinatal
Association said: "The WHO figure of 15% seems good, but it's not adhered to by
developed countries. When we look outside Turkey, the rates of Caesarean
sections are rising there, too."
According to Sener, the number of Caesareans has grown for four main reasons.
First, he cites a lack of antenatal care which means that doctors are faced
with pregnant women with unknown risk factors. He does, however, allow for the
fact that the Ministry of Health is working to remedy the situation.
Second, he claims that a lack of trained nurses means that doctors 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 childbirth. The
third reason is a change in the type of pregnant woman. For example, they are
generally older, more averse to perceived risk, more likely to have had IVF (In
Vitro Fertilization) and be carrying twins or even triplets. They also may have
conditions that formerly would have prohibited pregnancy, such as diabetes or
The fourth reason, and perhaps the most revealing reason for the huge rise in
C-sections over recent years, is fear of litigation. According to a health
expert, "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."
Unfortunately, Turkish doctors are making decisions based on a fear of
malpractice, rather than on medical necessity.
Dr Bulent Tras, 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 if we consider this to be at
risk we have the right and duty to perform a caesarean," he said. "Because of
the work of obstetricians mortality in childbirth has fallen from 138 in 1,000
in 1978 to 21.7 today."
What neither doctor mentions are the two other reasons that doctors and mothers
choose C-sections. Doctors get profits from a surgery for which some charge as
much as 8,000 lira (roughly $6000) and the speediness of the procedure. A
skilled surgeon can perform 10 such operations in the same 24 hours in which he
might wait for a woman to go through labor normally.
Research done by Uludag University Medical Faculty in 2004, showed that 86% of
births in private clinics were Caesareans. "The increase in Caesarean rates 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," said Dr Kadriye Avci who took part in the study. Avci believes
mothers, who listed the baby's safety as their prime concern, were deliberately
under informed about the risks of surgical intervention.
Mothers like the option of a pain-free childbirth as well as the element of
control that Caesareans give them. Certainly none of the reasons given by Sener
can explain the huge number of women worldwide who asked to have C-Sections on
August 8 this year. However, the superstition that 08.08.08 was an auspicious
day may go some way in doing so.
The decrease in family sizes also means that middle income families can afford
private healthcare that larger families cannot. Unwilling to accept the
perceived risks associated with natural births, they opt for C-sections.
Some women are persuaded to have surgery after being told their natal waters
are inadequate or that the fetal heart rate is dropping. Such overly cautious
and misleading statements feed into the fear that many women have that giving
birth is an inherently dangerous proposition. Television shows that show
medical births often focus on problem pregnancies in which mother and child are
heroically saved by a doctor's surgical skills. This fosters an environment in
which surgical intervention looks like the norm.
At this point, childbirth 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 mother trust - her own body or a doctor with
ten years of training? There are other elements at play, too, because for some
moms pushing a baby out seems too messy, too painful and even too animalistic.
The upper class women of Turkey with their trim bodies 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.
Fazile Zahir is of Turkish descent, born and brought up in London. She moved to
live in Turkey in 2005 and has been writing full time since then.
(Copyright 2008 Fazile Zahir)