“Don’t expect the worst. I ended up with a way better experience than quite a few people I know in Germany.”
Rabat – For expatriate women giving birth in Morocco, it can seem like there are few positive birth stories. Those seeking a natural vaginal birth in Morocco are worried it is not the norm in clinics and their doctor will pressure them into a c-section.
Morocco World News interviewed and surveyed 21 women from 10 different countries about what it was like to give birth in Morocco, particularly as foreigners, for a three-part series on giving birth in Morocco. In addition to vaginal birth, the series covers c-section births and general advice.
Due to the private nature of birth, several of the women wished to remain anonymous.
One German mother whom I will call Anna offered a positive view of giving birth in Morocco after her experience in Marrakech last year. “Be ready to fight for your rights, do your research and don’t expect the worst. I ended up with a way better experience than quite a few people I know in Germany.”
She continued, “It wasn’t perfect and there [were] one or two things I would change if I could but in the end I had a natural birth and was treated with respect and care.”
As her labor intensified, Anna appreciated her midwife’s encouragement to keep going. The midwife “said I was made to do this and I’ll be fine and I’m thankful she encouraged me,” Anna said.
‘I just let her cut’
On the other hand, Anna experienced an episiotomy, a procedure where a care provider cuts an incision at the vaginal opening. Anna’s doctor performed the episiotomy after she had started pushing “because according to her the head needed too long to be birthed and I started to have [less] energy.”
Although obstetrician-gynecologists (OB-GYNs) used to perform episiotomies on most women, believing it lowered the risk of severe natural tearing, researchers have since found episiotomies actually increase the risk of severe tears.
Anna said she “kept saying no” to the episiotomy, but her doctor said she had to, and in the end Anna “just let her cut.”
Episiotomies have fallen out of common practice in many countries, although still popular in countries such as Portugal and Poland.
Although trends in the West are leading to a more “physiologic” natural birth with fewer medical interventions, change is slow to come.
In Morocco, where clinic policies are less rigid, reforms to facilitate natural birth could come faster. An American who works with a Moroccan doctor to train nurses at his clinic in maternity care, Charissa, said that processes are “beginning to change, and I hope it will change faster here than in America.”
“There are people who are forward thinking; there are people who are trying to make change,” Charissa reiterated.
Stages of childbirth
Obstetricians break down labor into three stages: Active labor, pushing and delivery of the baby, and delivering the placenta. Before a mother can enter the second stage and push her baby through the birth canal, her cervix must dilate to 10 centimeters, allowing her baby to descend out of the uterus.
Getting to 10 centimeters is the goal of labor contractions, but how medical staff respond in each phase of labor varies tremendously depending on their experiences, training, culture, etc.
Nurses, midwives, and OB-GYNs assess cervical dilation by performing vaginal exams. While some advocates of natural birth are not in favor of multiple vaginal exams, they are a common part of the birth experience.
Brooke, an American who gave birth in a Casablanca hospital last year, said she only experienced three vaginal exams. Staff checked Brooke after she entered the hospital for an induction of labor, right before she got an epidural, and before she started pushing.
Women understandably want a healthcare worker to ask for consent before inserting a hand into the vagina to perform a cervical check. Unfortunately, many healthcare workers across the world do not think they have to ask for permission.
Very frequent vaginal exams
A Filipina woman named Marissa who had a natural birth in Morocco last year said her care providers performed vaginal exams with practically every contraction. For reference, by the time women are in active labor, contractions come every 2-5 minutes.
Not only do multiple vaginal exams increase the risk of infection, many women find them very painful.
Marissa’s sister even encouraged her to stay quiet during her contractions so that nurses would stop doing the invasive exams.
In pain from the contractions, Marissa did not have the energy to ask the staff why they repeated the checks or tell them to stop. In Marissa’s opinion, it would not have made a difference. “Even if you tell it to them, they will not stop,” she said.
Frequent vaginal exams during labor was a common complaint MWN heard. Janine, a South African who gave birth in Fez last year, said her midwife performed a number of vaginal exams, and they were quite painful.
In fact, during prenatal appointments, Janine did not even realize that her care provider was about to perform a vaginal check when she did. She was not the only one to point out unwanted vaginal exams during prenatal appointments.
Among the several women who discussed these exams, one American said the exams in the early months of her pregnancy were a contributing factor in her changing doctors. “The first appointments I felt the vaginal exams were unnecessary and was not asked if I wanted them or not.”
Unwanted help with pushing
Experienced as a nurse in a delivery ward back in the Philippines, Marissa is no stranger to birth. But in the end, the doctor who delivered Marissa’s baby girl did not give her a choice in how the delivery happened.
When Marissa had fully dilated, the nurses told her to begin pushing her baby out. “They assisted me well,” she said. They were encouraging, telling her she was pushing well even though she had an epidural. However, at the same time, the two nurses pushed on her belly to help the baby descend into the birth canal.
There is no solid evidence for or against external pushing by medical personnel, called “fundal pressure.” Mothers should be aware care providers sometimes use the technique to assist natural birth in Morocco. Also common in Europe, fundal pressure has been the subject of lawsuits against healthcare workers.
Janine described the fundal pressure as her midwife punching her belly to help her push.
The pushing stage of labor can be arduous, and it is common for the process to take several hours for first-time moms. I myself pushed for just over two hours before my son was born.
In the US, the standard advice for obstetricians is that the pushing stage should not take more than three hours for a first-time mom without an epidural and four hours for a first-time mom with an epidural.
Marissa said she was barely pushing for long at all before the doctor used a vacuum to pull her baby out. She was surprised because the nurses had been telling her how well her pushing was going.
In fact, Marissa did not even know her doctor had instrumentalized her delivery until she discovered a wound on her baby girl’s head from the vacuum. Months later, Marissa’s daughter still bore the scar.
The former maternity nurse was quick to say she respected the doctor. However, Marissa said, she did not like the way her doctor delivered the baby. “She didn’t wait.”
Having a say in the interventions you receive during labor can dramatically alter your view of the experience. When her baby had not been born 10 days after his due date, Brooke discussed an induction of labor with her doctor. Instead of feeling under pressure, Brooke and her doctor decided together to proceed with an induction.
During her labor, Brooke also made the decision to not allow her doctor to break her water until after she got an epidural. She summed up her son’s birth positively. “I had my baby and it all went the way I wanted it to.”