BEIRUT – While the rate of births by cesarean section in Lebanon remains considerably above internationally recommended levels, the incidence of the procedure among refugee women comes with additional risks and hardship. The number of C-sections has been on the rise globally in recent years, causing concern among NGOs, governments and clinicians.
In Lebanon, while no exact data is available, the rate of cesareans is estimated to be around 50 percent – a staggering figure compared to the 15 percent considered normal by the World Health Organization.
When medically justified, cesarean sections can save lives. But considering that the procedure costs around three times more than natural deliveries and typically requires less time, convenience and economic profitability are suggested to be driving forces behind Lebanon’s high figure.
According to the WHO, cesarean section rates higher than 15 percent have adverse consequences on maternal and infant health, including a heightened risk of death of the mother and child. Women with limited access to comprehensive obstetric care who also live in poor sanitary conditions face even higher stakes.
According to UNHCR’s senior public health officer Michael Woodman, the issue is of major concern for the U.N. refugee agency, which allocates over 40 percent of its expenditure on Syrian refugees in Lebanon to maternity care.
“C-sections are a concern both in terms of costs and in terms of health,” Woodman told the Daily Star. “These surgeries are never risk-free and their long term effects might take several years to manifest.”
In 2013, UNHCR issued a new policy requiring all health facilities to provide medical justification for each C-section covered by the U.N.
According to Woodman, this helped curb the number of unnecessary interventions, but the 32 percent rate registered among the Syrian refugee population in 2016 is still of major concern.
The Daily Star reached out to Lebanon’s health ministry but did not receive comments on the reason for, or high incidence of, C-sections in the country.
According to a 2015 UNHCR report, 75 percent of the 61,820 Syrian refugees UNHCR referred to hospitals were women, reflecting the high proportion of obstetric care cases.
For each birth by C-section, UNHCR spends on average $350 more, Woodman said.
This contributes to pregnancy being the most expensive diagnostic category, with over $12 million spent in 2015, according to the report.
The misconception that a C-section is a worry-free procedure also impacts the number of surgeries, with many women even requesting cesareans. Lack of support for a natural birth from healthcare professionals can also leave women who would like to avoid surgery feeling they have no other option.
As soon as she became pregnant with her second child, Manal – not her real name – knew she wanted to deliver her baby naturally. Her first child, a 3-year-old boy born in rural Halab near Aleppo, was delivered via C-section. But the new baby was in the normal position – head-down, rather than feet-first – and Manal was determined not to have another cesarean. “I walked up and down the corridor in the hope it would help initiate the natural birth process, but nothing happened,” Manal said. “I asked the doctor why they wouldn’t let me try [for a natural birth], but he just said that the decision had been made. Before I had a chance to answer, I was sent off to surgery.”
Manal is one of many refugee women who share a similar story. At the Doctors Without Borders (MSF) maternal clinic in the Palestinian refugee camp of Shatila that Manal turned to for free medical assistance, Syrian women queue up to receive pre-and post-natal care.
“Once a woman has had a first delivery via C-section, most healthcare providers do not even consider natural birth an option,” said Chiara Montaldo, project manager of the Shatila Medical Clinic.
Despite the WHO’s recommendation to try for a vaginal birth after a cesarean, surgery often puts a woman on track to have every subsequent child by C-section.
According to Montaldo, “This has adverse consequences, particularly on young mothers who risk serious complications if they give birth by C-section multiple times.” These could include uterine rupture, hemorrhage and deep vein thrombosis.
In settings like Shatila, where the water is salty and the sanitary conditions are poor, the risk of infection is also a major concern.
As well as the increased health hazards, higher expenses associated with C-sections also burden the refugees themselves. UNHCR covers 75 percent of the general cost, while the remaining 25 percent must be paid by the patient. For a refugee, delivery via C-section costs around $150 – three times more than a natural birth.
With their savings depleted, Manal and her husband had to borrow money from friends in order to deliver their second child.
The MSF clinic helps patients cover the costs of a C-section, even if the clinic does not agree with the choice to perform the surgery.
“We see women who have been referred to hospitals as a means of precaution come back with a C-section, even if our prenatal screenings did not detect the need for a cesarean birth as a first option,” Montaldo explained. “We expect at some point in the future to be confronted with the long-term consequences of this growing phenomenon.”