“Almost every [birth] story I read involved a c-section for various reasons,” Aliyah said.
Rabat – For anyone giving birth in Morocco who plans to deliver their baby vaginally, the high percentage of births by c-section in private clinics can be concerning.
In a three-part series on giving birth, Morocco World News learned about the birth experiences of women, particularly foreigners, in Morocco. Based on interviews and surveys of 21 women from 10 different countries, the series began with general advice and will cover vaginal birth in the final part.
When Claire found out she was pregnant in 2017, she was full of joy. In her mid-40s, the British woman wanted a vaginal birth instead of a scheduled c-section. When Claire first visited a doctor in Marrakech, he acknowledged she was healthy and fit but there was no way he would allow a 45-year-old to have a natural birth.
Claire proceeded to meet four other obstetrician-gynecologists (OB-GYNs), and most shared the opinion that older mothers should have c-sections as a matter of course.
The fifth doctor she met agreed Claire could try for a vaginal birth, but as the pregnancy progressed, the doctor “more than encouraged” a c-section. It was just the beginning of what Claire said became an “extremely traumatizing experience when I believe it really didn’t need to be that way at all.”
C-sections are a safe and often life-saving operation for complicated births. An OB-GYN may recommend one for numerous reasons. Some of the most common reasons are if the baby is in an abnormal position, if labor has stalled, if the mother had a previous c-section, or if the baby’s heart rate indicates distress.
C-sections: A popular choice
Despite the length of time it takes to recover from a c-section and inherent risks of major surgery, some mothers choose a c-section over a vaginal birth for non-medical reasons. They may want to have more certainty over the timing of birth, to avoid the pain of labor, or to avoid other complications.
Indeed, many expectant mothers in Morocco request them, noted Charissa, an American maternity nurse who works with a Moroccan OB-GYN as a birth educator in Marrakech.
The World Health Organization estimates c-sections are necessary in 10-15% of births. One study found that the rate of c-section births increased more in Morocco, Egypt, and Tunisia, than in any other African country in the 24 years from 1990 to 2014. In 2011, the official c-section rate in Morocco was 16%.
However, the rate is much higher in urban areas than in rural areas, and it is higher in private clinics than in public hospitals. The National Fund of Social Welfare Organizations (CNOPS) in Morocco reported the c-section rate was 61% in 2017 among births it was liable to reimburse.
Anecdotally, women report of c-section rates upwards of 50% with certain doctors.
C-sections pay more for doctors, but the high rate of c-sections in Morocco is not entirely down to doctors cajoling women. When “your patients are asking you for cesareans, you’re gonna do that,” said Charissa.
Amal, a British woman who gave birth in Sale in 2017, told MWN 40% of the births her doctor delivered were c-sections. The doctor explained “her rate [of c-sections] was high because some women have an elective section and she’d do them.” A previous doctor Amal visited had a c-section rate of 70%.
Among women planning to give birth in Morocco, some fear their doctor will pressure them into having a c-section because of a lengthy labor or a presumed large baby.
One Canadian who works in the birth field in Fez advised pregnant women to “know the tactics of pushing for c-section.” Genevieve Lepage highlighted that some doctors perform “radio pelvimetry” to ascertain the size of the baby’s head in relation to the size of the mother’s pelvis.
After assessing pelvimetry, a doctor may advise a woman that if she tries a vaginal birth, her pelvis will not be big enough to birth the baby. However, a study on pelvimetry found it “is a poor predictor of the outcome of labor, has no influence on the neonatal issues and increases the cesarean sections rate.”
‘Almost every birth story involved a c-section’
In fact, some women change doctors because they are concerned about pressuring tactics. Aliyah, an American who gave birth last year in a small town called Mirleft shared that her original doctor “wouldn’t tell me [her c-section rate] but said if everything looked good around birthing time there was no reason for a section. I didn’t trust her though.”
“Almost every [birth] story I read involved a c-section for various reasons,” Aliyah said. Two weeks after her due date, when she had not yet given birth, Aliyah said her doctor “was really trying to scare me into a c-section.”
In the end, Aliyah delivered her baby herself in the comfort of her own home.
Erika, an American who gave birth in Rabat last year, was very grateful for her doctor’s guidance to have a c-section when her labor stalled.
After hours in labor with no significant progress, Erika gave birth by c-section with her husband present.
During the c-section, Erika’s doctor realized the baby’s umbilical cord was really short. Not only does Erika believe her doctor prevented her from experiencing more hours of fruitless labor, her baby boy would have been at risk if she had not delivered by cesarean.
Although the c-section was not part of her plan, Erika’s birth experience in Morocco was very positive. “Everyone there throughout our entire process from beginning to end treated us with respect and listened to us,” she said.
After Erika gave birth, her doctor allowed immediate skin-to-skin bonding for 10 minutes.
As recently as 2009, only 32% of babies in the US got skin-to-skin bonding immediately after an uncomplicated cesarean. However, the trend is moving towards more skin-to-skin. By 2015, the percentage was up to 70%.
A British woman who gave birth by c-section in Morocco in 2012 and wished to remain anonymous said she wanted immediate bonding, but staff prioritized cleaning up her baby. “I did not feel listened to,” she said.
For British mom Katie, who gave birth by c-section in Rabat last year, it was a different story. Katie said her care providers observed her specific wishes for the birth. Explaining her husband was able to stay with her during the operation and she got immediate and prolonged skin-to-skin time with her baby, Katie said she “felt listened to.”
‘I had no say’
Claire’s c-section came about due to a high blood pressure reading on a hot summer day. High blood pressure in a pregnant woman can be a sign of preeclampsia, a serious condition that if not treated (by delivering the baby) can be fatal for both mother and baby. However, Claire says, she had taken tests for preeclampsia, and the results came back fine.
Nevertheless, Claire’s doctor sent her to get a c-section at the clinic the next day, about a month before her due date. Once there, Claire relied on her husband to translate for her.
The clinic, midwife, and OB-GYN had previously agreed to allow Claire’s husband to stay with her. But the mood changed when he asked a question about what was in the syringe when a nurse was about to inject Claire.
Two doctors told Claire’s husband he had to leave. They relented in response to Claire’s pleading, but shortly after sent him away anyway. The same clinic later allowed Claire’s friend to have a c-section with her husband present.
“I had no say in anything,” Claire said. “I believe my husband was deliberately kept out so they could minimize any questioning.”
Claire requested to bond with her baby skin-to-skin immediately after the birth. But when the operation was over, she only saw her baby girl for a moment before staff took her away. Claire would not see her daughter again for 24 hours.
During that period, the clinic gave Claire no food and allowed her no water, putting her on an IV instead. A breastfeeding nurse, however, said the IV was insufficient, dehydrating Claire and preventing her from pumping breastmilk.
Claire was also upset that staff fed her baby formula against her request. Newborns typically need very few calories in their first days of life, but when they nurse, their mother’s body prepares to produce milk. If infants take in formula, they are often not as interested in nursing and do not signal their mother’s body to produce milk. That can complicate future breastfeeding attempts.
After a day, the clinic allowed Claire to see her husband and baby again and soon after, they went home. Thankfully, mother and daughter succeeded in establishing breastfeeding after the delayed start.
What is the norm?
Charissa, whose work in a Marrakech clinic involves training nurses on maternity care, said she sees a trend toward allowing fathers to be present at the birth. When she gave birth herself by c-section, Charissa’s doctor allowed her husband to be in the operating room.
After delivering the babies of multiple expatriate women, the doctor had become used to foreign women’s requests to have their partners with them, Charissa said.
At the same time, Charissa notes, it is not at all the norm to allow other support people, such as “doulas,” into the birthing room or operating room. “Most clinics have a ‘nobody in there with you’ rule.”
“But,” she says, “I am hoping and working towards change in this area.”
While many foreign women giving birth by c-section in Morocco are concerned they will be alone in the operating room, others, like Charissa and Erika, share positive stories where their partners were allowed to be present.
However, the coronavirus has had an effect on policies, with at least some clinics preventing any support people from accompanying the mother during the operation or recovery period.
Pack painkillers in your hospital bag
Many people think of c-sections as a painless way to give birth. Like all surgeries, however, the recovery is painful. Often, Western doctors prescribe strong painkillers such as opioids to women recovering from c-sections.
Charissa advises women giving birth in Morocco to “bring [strong] pain medication with them … whether they are going to have a cesarean or not.”
Typically, doctors in Morocco will prescribe some medication after c-section, but it may just be paracetamol. They may expect patients not to need more in the days following surgery.
An American whom I will call Jessica described the lack of pain medication after her c-section birth in Morocco. “Starting the next day postpartum, all I was getting was paracetamol, and that was not enough.”
Especially for patients more familiar with Western medical practices highly concerned with alleviating pain, it is important to realize that in Morocco, as Charissa said, “Giving pain meds is not a regular practice.”
While women can ask their doctor to prescribe medication for the inevitable pain of recovering from a c-section surgery (and the pain of afterbirth cramps for a vaginal delivery), they may still have to advocate for themselves with nurses.
Jessica said it was not a cost issue but seemed to be “more of a cultural no-no to be taking heavy painkillers.” Every time she asked nurses to bring her more painkillers, they would delay by telling her to wait for a bit.
Commenting that many Moroccans receive no medication to dull the pain of excruciating dental procedures, Charissa said, “Moroccan women are really strong and they can tolerate a lot of pain.”
One Moroccan-American who preferred to remain anonymous said she wished she had better prepared for the “horrible pain I felt after C-section.”
British mom Amal faced the nightmare of her anesthesia not working during the actual surgery. It is not unusual across the world for women to experience a failed epidural at the beginning of surgery, but Amal said her medical team was not prepared to deal with her pain or to find alternatives.
Instead of finding a solution, she said, “the theatre staff … were trying to dismiss the fact that I was in pain and could feel exactly what was happening.”
Ultimately, each doctor and clinic may have different practices. And some women may experience more positive births through c-section in Morocco than many women have in countries with more advanced healthcare.