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Crimes against women behind operation rooms’ doors

The paralyzing feeling of the epidural shot— an injection in the spinal cord to stop sensation in the lower body—did nothing to ease the unbearable pain of Ghadeer Tarek’s contractions.

Tarek, who longed to hold her baby in her arms, is a survivor of obstetric violence who never had the chance to see her baby.

Obstetric violence is defined as any practice that threatens women’s freedom of choice or body autonomy during labor.

The practices that are classified as obstetric violence range from denial of the presence of a companion of the women’s choice, lack of information about the different procedures performed during labor, deprivation of the right to food and walking, and routine and repetitive vaginal exams without justification.

Obstetric violence can also come in the form of frequent use of oxytocin, a hormone prescribed as a drug used to induce labor.

A study conducted in the Gondar University Specialized Comprehensive Hospital in Northwest Ethiopia showed that three of four women participating in the study were subject to at least one form of violence during labor.

These types of violence varied from non-consensual care (63.6 percent), non-dignified care (55.3 percent), physical abuse (46.9 percent), non-confidential care (32.3 percent) neglected care (12.7 percent) and discriminated care (9.3 percent).

Another practice that denies women the ability to make informed decisions regarding their childbirth is the unnecessary usage of a cesarean section instead of natural vaginal delivery.

Egypt comes in third highest cesarean section rate (54 percent) in the world. Cesarean sections are easier for the medical staff and take less time, but it takes more time in the healing aftercare period.

Things were not always this way, as the cesarean section rate has been going up exponentially. Egypt went from 4.6 percent in 1992, 6.7 percent in 1995, 10.3 percent in 2000, reaching 52 percent in 2014.

However, around the world—data from 121 countries—the average grew from 6.7 percent to 19.1 percent from 1990 to 2014.

According to Dr. Sherif Akl, a gynecologist and professor in Ain Shams University, more than 90 percent of his natural births include the episiotomy procedure, which is usually not recommended unless in rare circumstances.

These include when a woman’s perineum is going to tear as the baby comes out, thus the episiotomy can help prevent this tear and speed up the process if the baby’s condition requires a quicker delivery.


“I knew something was not right”

Tarek experienced more than one form of obstetric violence during her first ever childbirth experience.

She screamed as she felt every bit of the pain – however no one, out of the 12 people standing in the operation room, bothered to listen to her.

“They were treating me disrespectfully after they gave me the wrong anesthesia that didn’t numb me. My gynecologist kept insisting that I was being dramatic and faking my pain, but deep down I knew something wasn’t right,” explained Tarek.

Tarek’s story seems tragic to the point it would be a rare case, yet her tale is a common one.

According to an online survey on American perception of birth pains conducted 2018 by Vani A.Mathurab, Theresa Morrisc and Kelly McNamarac only two respondents (one percent) mentioned that women go through psychological pain during labor along with physical pain, showcasing a lack of cultural knowledge of the biopsychosocial nature of pain.

Tarek’s story did not end happily.

After a good two hours of suffering, the young inexperienced anesthesiologist gave her another epidural shot without her consent or her family’s.

Dizziness, slow heart rate, and stronger pain kicked in because of the unsupervised dose of anesthesia. She was feeling her child’s head emerge, ready to meet the world, and she was waiting for her newborn’s first cry to warm the cold, tense room.

“If the epidural shot did not paralyze the lower body, then the needle was not placed in the right place,”  explained anesthesiology resident Menna Ayad.

Ayad added that shifting from epidural to general anesthesia during a surgery needs the verbal consent of the patient unless it is an emergency that includes severe bleeding.

Tensions only increased between the 12 people in the operation room. Tarek was begin to slip out of consciousness, forcing them to slap her awake. She tried to lift her light head with a lot of effort to try to see what was happening to her child.

“What’s happening?” she asked.

A question that came out low and weakened before the cold, confident hand holding her arm that could not resist and gave her a general anesthetic shot. Then, darkness.

Tarek’s life had been at risk, and the doctors broke the baby’s ribs while trying to perform CPR, as they told the family.

She lost her child during labor.

Consent is not clearly stated in the Egyptian medical code of conduct, however as explained by the Code of Professional Ethics of the American College of Obstetricians and Gynecologists: “The obstetrician–gynecologist has an obligation to obtain the informed consent of each patient. In obtaining informed consent for any course of medical or surgical treatment, the obstetrician–gynecologist should present to the patient, or to the person legally responsible for the patient, in understandable terms, pertinent medical facts and recommendations consistent with good medical practice.”

Even though Tarek agreed to go through the episiotomy, the cut was done with the wrong angle, leaving her with an infected wound that took months to heal.

“C-sections are not even double natural births, it is ten times more,” said Alaa Mubarak, a nurse who worked in gynecology in a public hospital for two years. “I think most doctors do it because it is easier for them as cesarean section is a straightforward procedure instead of waiting all day for the natural labor to take place,” she added.

C-section rates according to Akl— who has been practicing medicine for more than 40 year— are the second most common in Egypt in comparison to the rest of the world in total labor operations.

Episiotomy is another common practice that falls under the fluid umbrella of obstetric violence. It is defined as a surgical cut in the perineum—the tissue between the vaginal opening and the anus—during childbirth to ease the delivery, without the consent of the women. The problem with this is that episiotomy can cause further implications such as infection, pain during sex afterwards and fourth degree vaginal tearing that could cause fecal incontinence.

Thus, women need to know the risks beforehand to decide for themselves.

That’s why it should not be considered as a routine procedure due to its possible implications.

“My doctor conducted an episiotomy during my labor. I knew that sometimes they have to do it if the baby’s head is big or whatever, but the doctor did not agree with me beforehand nor asked me before doing it and he did it anyway,” said Eman al-Dars, another obstetric violence survivor.

Kristeller’s maneuver, which is a practice in which manual pressure is applied on the upper part of the uterus during labor’s second stage, is still applied without consent of the mothers. It was proven in a study published in the US National Institutes of Health that even though there is not enough evidence on its benefits or harms, vaginal and perineum tears were reported in 33 percent of the cases where Kristeller’s maneuver was applied.

Other impacts of the Kristeller’s Maneuver are Levator Ani muscle injury which is reduced pelvic floor muscle strength, enlargement of the vaginal hiatus and pelvic organ prolapse.

Al-Dars also spoke up about her experience with Kristeller’s Maneuver.

“The first thing that happened is Kristeller’s Maneuver where they apply pressure on the belly to push the baby out..it was painful, and I had trouble breathing because of the amount of pressure on my belly and coughed. The doctor kept telling me to stop coughing and man-up, but I just couldn’t breathe,” she said.

As Mubarak explained, “We learned that applying pressure on the woman’s belly is dangerous and can even cause serious implications for the baby and the uterus, yet I worked with many gynecologists who still do it.”

She added that an episiotomy happens in more than 80 percent of natural births.

Mubarak recounted how once, she worked with a female doctor who used to do an extra stitch for the episiotomy wound to further “tighten” the vagina, and that it is sometimes at the request of the husband.

It is for the purpose of what she called “better sex” for the husband. This practice is commonly called the Husband Stitch, in which the gynecologist stitches the vagina as a “compliment” to the husband.

“Of course we know that this is medically wrong because the vagina is a muscle that contracts and relaxes, and the 40-day-healing period after giving birth is more than enough for the vagina to go back to its natural size,” Mubarak added.

A victim who chose to stay anonymous went to the gynecologist clinic and was assured by the nurse that she would get examined by the doctor’s female assistant, and was directed to the examination room.

A few minutes later, the doctor came in, in a hurry to get it over with. She refused the examination, and he told her she was exaggerating and pressured her into the vaginal examination.

“I explained to him that I don’t want to be examined by him in person while covering my body with sheets, but he said that he does not have time for this behavior” explained the 58-year-old victim.

She added that this happened back in the day, and that it was hard for her to refuse or speak-up as he was a well-known and reputable doctor.

Obstetric violence occurs on a rather large scale in Egypt.

However, accurate statistics about it are difficult to obtain because women who face it are usually not aware of it, and they do not even register such practices as violence.

So, the actual cases are not recorded and even if they are there are no efficient authoritative data collection sources to combine the findings.


Don’t Look Down

Although it seems easy to spot these wrongdoings and simply fight them, the reality is not so simple – especially in Egypt.

Women generally do not have access to information about their maternal and sexual health starting from school education until preparing for marriage.

In Egyptian schools that follow Ministry of Education’s curricula, there is no subject that aims to educate students about sexual life.

This leaves them with only one source to get any information about sex, gender and one’s body from a sexual perspective – either biology in high school or science in middle school.

In these two subjects, only the reproductive systems of males and females are explained.

Akl explained that most of his patients have two sources of information about obstetrics; family and friends or Google. He believes that this is not enough for a woman to know specifically and scientifically what to expect during labor because usually the information on the Internet can be misleading.

Even information that is obtained from family and acquaintances are typically personal experiences that differ from one person to another.

The result is that women go into the gynecologist’s office, and later to the operation room, with little to no information, so she takes his words for granted, as Arab societies usually respect medical doctors to the extent of believing their judgments without question.

The lack of education is also why women have a disconnection with their bodies starting from the experience of having sex. Akl thinks that the fear of natural labor that many women have is because intercourse is already painful for them due to the lack of sex education.

So, they prefer undergoing a surgically invasive delivery than having a vaginal one because of this fear.

There isn’t even a subtle explanation of how sexual intercourse between a man and a woman happens in Egyptian education curricula. The curricula only focus on the biological processes before or after intercourse without mentioning sex by any means.

This leaves a huge question mark in students’ minds.

“I am studying the reproductive system for the first time this semester. However, I was not able to understand how a man and woman have sex. So, I Google anything that I don’t have an answer for, or I discuss it with my friends,” said Jana Elabasy, a grade-nine-student in an Egyptian national school.

The fact that this is the extent to which teachers neglect that part of the syllabus shows how most women grow up not knowing much about their bodies and giving birth specifically.

Elabasy seemed to have many misconceptions about sexual intercourse as her only source of knowledge is the internet, which is a wide sea of information that is easily misleading. Her other option is her friends, who also have misconceptions that they pass on.

The social stigma against women’s bodies is another contributing factor that hinders women from saying no to crimes that are committed under the name of medical practices.

“Medicine is a system that does not take into consideration women’s pain and is already undermining women’s bodies and ignoring women’s experiences, their preferences or pain. The idea that women’s pain is considered less has been known of all time; for example there is a great underestimation of period pain, while research shows it is almost equal to a heart attack,” said Dina Makram Ebied, assistant professor of sociology at the American University in Cairo.

This neglect from the medical community towards women’s expressed pain and consent over procedures pertaining to their bodies reflects how society perceives women’s sexuality.

It is very often that teenagers are denied the right to know about their bodies, as it is deemed “inappropriate” to talk about it before marriage.

“I stopped asking questions as I am always told not to discuss grown-up topics,” said Elabasy.


Physical vs. social pain

Akl explains that more than 50 percent of his births conducted in his private clinic are C-sections.

“I think that a maximum 15 percent of women should undergo C-section, but here in Egypt, there are areas where 90 percent of women give birth surgically, and one of the reasons for this is the fear of natural childbirth amongst women,” Akl emphasized.

He said that doctors are responsible for the high cesarean rate because they tend to be afraid of natural birth as it is more risky for the baby.

Reputation is essential in the medical profession, he noted, as Egyptian society is not very forgiving when it comes to accidental medical errors that would lead to losing the baby, for example.

The objective here is clear for the doctors – protecting their name and reputation.

For medical context, it is vital to mention that the problem with C-sections is that if a women choose cesarean delivery more than once, she is more prone to have problems in the placenta that would cause internal bleeding and health repercussions to adjacent organs, which Akl explained is a a very common condition for women who undergo C-sections.

This condition may lead to premature birth or even the removal of the uterus.

“This specific issue is why the C-section should be avoided as much as possible,” he stressed.

It is often argued that some doctors push women towards C-sections as it is more profitable for them; however, Akl disagreed saying that he and most other gynecologists now charge the same price for natural and cesarean deliveries, except for a small added amount that accounts for the materials needed for the surgery.

Another reason that doctors prefer C-section labor other than health risks and money is time.

Natural labor is more lengthy and tiring than C-sections- a natural delivery session could last up to six hours, while cesarean section takes barely 30 minutes.

This leaves doctors able to do more cesarean deliveries daily than natural ones.

Akl justifies this by mentioning how doctors are usually under a lot of stress and barely have time for their personal or social life, as they have to be alert for any emergency around the clock.

Awareness about obstetric violence is extremely crucial because it is a subtle type of gender-based violence that is barely heard of. It is more prevalent than a husband’s black eye or a father’s honor murder and can easily be justified with so-called medical reasons.

“I think I am traumatized from this experience that I will not get pregnant and have children ever again,” Tarek said.

She is far from the only victim.

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