Over the past decade, Syria has experienced an alarming surge in C-section deliveries, a consequence of the ongoing security crisis since 2011 and the resulting economic and healthcare system decline.
In 2019, global statistics revealed Turkey’s high C-section rate of 54.4 percent (544 children out of every 1,000 births). Shockingly, Syria’s rate at that time, amidst eight years of conflict, was even higher, with 630 out of every 1,000 children born through caesarean section (C-section), accounting for 63 percent.
The World Health Organization’s recent studies and figures indicate that one in five children worldwide is born via C-section, raising concerns about potential harm, especially as the rate may reach approximately 29 percent by 2030. However, Syria’s rate remains disproportionately higher.
This investigation uncovers compelling statistical evidence from various sources, including Syrian government-controlled governorates in the post-2011 years. It reveals that factors such as security instability, lax oversight, and the greed of individuals and authorities within the medical sector have led to pregnant women being systematically pushed towards unnecessary C-sections, solely for financial gain.
Apart from the exploitation and corruption within the medical sector, the decline in the role of state institutions in promoting awareness and providing care has further victimized pregnant women and their children, resulting in them paying a heavy price in terms of health, finances, and psychological well-being. This phenomenon not only affects their future but also poses significant implications for future generations in the country.
Alarming Surge: C-section Rates in Syria Soar Fourfold Above Global Guidelines
An extensive investigation delved into official data from the Syrian state, covering birth records and delivery methods in both public and private hospitals from 2010 to 2021, as well as data from the first half of 2022.
The analysis of C-section deliveries in Syria reveals a concerning trend, with the percentage of C-section births skyrocketing from 29% in 2010 to a staggering 57% in 2020.
In 2019, C-section deliveries reached an all-time high, accounting for 63% of all births. This rate is nearly four times higher than the World Health Organization’s recommended global ideal rate, which should be between 10-15% of all births.
It’s worth noting that the investigation’s comprehensive data includes hospitals under the Ministry of Health, but does not encompass hospitals affiliated with the Ministries of Education and Defense, private clinics, or home deliveries.
Rising C-section Rates in Private Hospitals: A Troubling Trend
Available data reveals a concerning surge in C-section deliveries within private hospitals. In 2010, C-section births accounted for 50% of all deliveries, but since 2011, these rates have been on a continuous climb, peaking at a startling 76% in 2019.
During 2019, out of a total of 47,721 births, 36,521 were carried out via C-section, while only 11,669 were natural births. The following year, in 2020, C-section deliveries remained alarmingly high, comprising 74% of the total number of births.
However, it’s essential to note that the figures for 2019 and 2020 do not include data from the governorates of Raqqa and Idlib, which are beyond the control of the Damascus government. Additionally, data from private hospitals in Deir ez-Zor and Quneitra were unavailable.
In 2019, Daraa, Tartous, Lattakia, and Damascus reported the highest rates of C-section, reaching 96%, 94%, 92%, and 80% respectively. Daraa alone witnessed 10,680 C-section deliveries, accounting for 72% of all births. Although C-section rates in this governorate slightly decreased to 67% in 2020, the overall number of C-section deliveries rose to 11,321.
Responding to concerns about the high C-section rate, the Syrian Ministry of Health stated that it had launched a plan to provide better care for every live birth, which was successfully implemented in some government hospitals. This initiative aimed to reduce the rate of C-section in private hospitals. However, further measures might be required to address the persisting issue.
Record C-section Rates in Damascus: A Troubling Trend
The percentage of C-section deliveries varies significantly across different governorates in Syria, with Damascus private hospitals experiencing a striking increase from 56% in 2010 to 73% in 2020. The peak was observed in 2018, reaching a concerning 85%, meaning that 85 out of every 100 children were born via C-section.
In 2022, an anonymous official from the Syrian Ministry of Health disclosed that certain private hospitals in Damascus had reached a shocking 100% C-section rate, with no natural births reported throughout the year.
Similarly, public hospitals under the Ministry of Health also saw a substantial rise in C-section deliveries, climbing from 19% in 2010 to 47% in 2021. The latest available statistics for the first half of 2022 show that 49% of all births were C-section deliveries.
The highest increase in C-section rates in public hospitals occurred in 2019, with 56% of 81,514 births being C-section deliveries. This represents a three-fold increase compared to the rate recorded in 2010.
An anonymous doctor from a public hospital suggested that the hospitals attempt to control unnecessary C-section, except in rare cases where pregnant women pay doctors outside the hospital to perform a C-section delivery later. The Ministry of Health acknowledged these cases in response to the investigation’s inquiries.
Despite efforts to justify the discrepancy in C-section rates between public and private hospitals, the data from the past 11 years indicates that the control measures have not succeeded in maintaining normal rates. Instead, the rates have far surpassed global averages. In June 2021, research published by the World Health Organization (WHO) revealed that C-section deliveries accounted for only 21% of all births worldwide.
As soon as Heba (35 years old) felt the symptoms of labor and the birth of her first child in the city of al-Nabek in the countryside of Damascus, she immediately rushed with her husband and mother to the nearest government hospital in the city. After waiting for about 12 hours, she was forced to have a C-section, even though there were no medical indications for it. The only reason was the security situation.
In 2013, the armed conflict between government forces and opposition factions was at its height in the Qalamoun region in rural Damascus. Heba said, “Our only concern was getting to the hospital without being hit by sniper fire.”
Heba waited on the government hospital bed from 1:00 AM to 12:00 PM. The nurse and doctor on duty confirmed that the condition of her uterus and amniotic fluid were good, and there was no need for a C-section.
“The hospital was not well-equipped at the time,” Heba added. “There were multiple births taking place around me, and I was only separated from the other patients by a curtain. This had a negative impact on my mental state, and I asked to be discharged.”
Heba then went to a gynecologist in the area who had converted part of his private clinic into a mini operating room. He told her that she needed an urgent C-section, claiming that the opening of her uterus was contracting and the waters had begun to leak from the fetus.
“I think the doctor just wanted to end the birth quickly,” Heba said. “The clinic was not equipped, either in terms of sterilization or blood bags. The amount of anesthesia was not sufficient, and I woke up during childbirth.”
The doctor completed the operation within less than an hour and then discharged Heba “for fear that the place would be bombed,” she said. However, the C-section wound became infected several months after giving birth. It partially opened due to the poor type of sutures and lack of sterility, according to another doctor that Heba saw. She then had to see a general surgeon.
Many women have been subjected to circumstances similar to Heba’s. Obstetrician Nizar attributes the increase in the rates of C-section deliveries between 2012 and 2015 to the security factor.
In a 2013 briefing, the United Nations Population Fund noted that the “crisis” and “conflict” conditions in Syria “force pregnant women to opt for C-sections.”
Doctor Nizar (a pseudonym), who went through this stage during his work in government and private hospitals inside Syria, said, “Going out of the house was dangerous for both the pregnant woman and the doctor, so C-section was preferred by both parties.”
Ahlam (a pseudonym), who is also a doctor specializing in obstetrics and gynecology in Damascus, agrees with her colleague about the role of the security situation during the war.
The statistics obtained by the investigation indicate that the rate of C-section jumped from 29% to 50% during the five years between 2011 and 2015.
In 2015, there were 101,957 Syrian children born, about half of whom (50,973 children) were born through C-sections.
Fear and Aesthetics Drive Demand for C-Sections
Rania, a 30-year-old woman, opted for a C-section driven by her personal fear of natural childbirth, which she had envisioned to be daunting. Additionally, her choice was influenced by her doctor’s practice of not performing normal deliveries, as shared by other patients and secretaries.
“I could have had a normal delivery, but I decided beforehand to go for a C-section in agreement with the doctor,” Rania explains.
Similarly, Bayan, aged 28, underwent a C-section delivery at a private hospital in Damascus without any medical indications due to her fear of labor pains. However, her doctor did not adequately explain the pros and cons of both natural and C-section deliveries to her.
Dr. Mona, an obstetrics and gynecology specialist, highlights that some couples opt for C-sections to maintain the aesthetics of a woman’s genitals, avoiding the possibility of vaginal expansion resulting from multiple natural births.
Apart from this, Dr. Nizar attributes the increasing demand for cesarean sections to the prevailing social culture, where some women prefer to give birth early in pregnancy. He emphasizes that doctors must ultimately respect their patients’ wishes and cannot force them into natural childbirth, despite their medical oath.
Dr. Ahlam also observes that some pregnant families occasionally press doctors to perform cesarean sections. Additionally, the rise in cesarean deliveries is also explained by a large number of mothers having a history of previous cesarean births, especially when there are medical indications for a second birth.
Surgery is a source of profit for doctors: A Cause for Concern
Women interviewed during the investigation shed light on a concerning practice among some doctors who prefer not to accept cases of natural childbirth due to time constraints and perceived inadequate financial returns. These doctors charge additional amounts from pregnant women who have health insurance coverage, over and above the operation’s cost, which should typically be covered by insurance.
Rania, a teacher at the University of Damascus who has health insurance, gave birth to her first child by C-section in a private hospital in Damascus in 2019. The total cost of the birth was 400,000 Syrian pounds, but she only paid 40,000 pounds to the hospital under her insurance contract, or 10% of the cost.
Some doctors collect the price difference from the insured patients themselves, rather than being paid by the insurance company. This is what happened to Rania, who says that the doctor “also got his fee a week before giving birth, separate from the hospital fee, even though he was supposed to get it from the insurance company later.”
An official source at the Insurance Supervisory Authority in Syria, who asked not to be named for personal reasons, admitted that the authority had received complaints since the beginning of 2022 from people who had been charged price differences by hospitals.
Dr. Nizar believes that the issue is not so much about the lucrative returns of C-sections, but rather about the unfair rates set by health insurance companies. He says that doctors do not want to be interrupted from their work in their clinics for long periods of time, waiting for pregnant women to give birth naturally. As a result, they are willing to accept lower wages from insurance companies for natural births, but they charge higher fees for C-sections.
The official at the Insurance Supervisory Authority confirmed that the wages of surgeons who perform C-sections for insurance companies used to be capped at 75,000 Syrian pounds, but today they can reach as high as 302,000 pounds for each birth in some hospitals.
Dr. Ahlam points out the vast differences between the wages for C-sections and natural births that doctors receive in Syria. She says that the wages for C-sections are higher than for natural births, which is one of the factors that contributes to the high rate of C-sections in the country. Even when the insurance company pays an appropriate amount for the doctor’s work, the hospital often takes a large portion of the wages for itself.
The official at the Insurance Supervisory Authority says that the authority issued a circular on August 4, 2022, stipulating that doctors’ wages be transferred directly to them, and not through the hospital. This is to protect the doctors’ rights, as the insurance companies used to transfer the wages to the hospital first, and then the hospital would transfer them to the doctors. However, the hospital would often delay paying the doctors, or the wages would arrive incomplete.
Dr. Ahlam gives an example of this, saying that when she contracts with an insurance company, she is paid 100,000 Syrian pounds for each C-section, but only 15,000 pounds for a natural birth. She says that she and many of her colleagues terminated their contracts with the health insurance system more than a year ago due to inflation, the differences between insurance prices and private practice births, and the delays in doctors receiving their surgery fees from insurance companies.
The official at the Insurance Supervisory Authority says that the withdrawal of doctors from the health insurance network was widespread before the first month of 2022, due to the “resentment of doctors” towards low wages and delays in payment of dues. The source confirms that the supervisory authority has warned insurance companies that, starting from the claims (invoices) for the month of August 2022, a payment period for surgeons not exceeding 45 days must be adhered to, under penalty of suspending their work or revoking their license.
The prevalence of hysterectomy is on the rise.
According to data from the World Health Organization spanning from 1990 to 2017, there is a heightened risk of maternal mortality following C-sections. Shockingly, a quarter of all women who died during childbirth in low- and middle-income countries had undergone a C-section. Moreover, statistics reveal that the infant mortality rate in these countries is a staggering 100 times higher compared to high-income countries, with up to a third of all babies losing their lives, as reported in data from 12 million pregnancies.
Specialized medical authorities and references warn about the adverse consequences of cesarean sections on both the child and the mother. These include the need for blood transfusion, the risk of complications from anesthesia, organ injury, infection, thromboembolic disease (blood clots), and respiratory issues in newborns. Other potential complications include rupture of the uterus, ectopic pregnancies, placenta accreta, infertility, and intra-abdominal adhesions in subsequent pregnancies.
Turning to the situation in Syria, Dr. M.T. confirms encountering cases of mothers facing health issues after a cesarean section, stating, “Unfortunately, instances of placenta with defective attachment and insertion (placental adhesion to the uterine muscle) are increasing, leading to a higher likelihood of bleeding and requiring hysterectomy.”
A doctor from a government hospital explains that due to the increase in placenta previa and bleeding cases, “both male and female doctors are compelled to perform uterus removal surgeries.” Hospitals are also witnessing frequent cases of placenta attached to the scar from a previous C-section and ectopic pregnancies outside the uterine membrane.
Dr. Ahlam also affirms, “The percentage of patients suffering from placenta praevia has increased, mainly due to the rise in cesarean deliveries overall.” Additionally, she notes that Al-Zahrawi Governmental Hospital reviews one or two cases of neonatal hysterectomy for mothers with a history of C-sections on a weekly basis.
Post-operative care costs range from zero to 1.5 million pounds.
According to a 2018 report by the World Health Organization, a significant number of C-sections are linked to high healthcare expenses. In Syria, the cost of medical care for a C-section delivery varies based on factors such as the hospital’s location, classification, and type (private or public). In the countryside of Damascus or city centers, private hospitals charge between 600 thousand and one and a half million Syrian pounds for a C-section. However, in the private departments of public hospitals, the cost is less, amounting to under 100 thousand pounds. In the general departments of public hospitals, the cost is nearly free, as per the accounts of patients and doctors who were interviewed for this investigation.
Unfortunately, with the worsening living conditions, post-cesarean care becomes an added burden for mothers and even their children. The inability to afford proper care leaves open the possibility of worsening injuries, as many mothers struggle to cover post-cesarean expenses. Several medical sources and women interviewed for this investigation have raised concerns about the challenges faced in securing post-operative care due to financial constraints.
Operations without medical indications
Years after experiencing the consequences of a C-section performed by a doctor in his private clinic, Heba found herself once again falling victim to surgeons’ scalpels during her second pregnancy in a private hospital in Damascus. She shared, “My second son was born via a C-section, even though there were no medical indications for it, just because my first birth was a C-section.”
According to the data, the high rates of cesarean sections are frequently associated with unnecessary operations. The investigation revealed four cases out of seven where women underwent C-sections without any medical necessity.
One such case is Alia, who had decided from the beginning of her pregnancy to give birth naturally. However, it seems that her doctor had different plans. Alia recounted what happened on the day of childbirth in a private hospital in Damascus, saying, “I informed the nurse that I intended to use a room assigned to my supervising doctor. Her immediate response was, ‘Then it’s time for another operation’ to perform another C-section in a row.”
During her pregnancy, the doctor had not discussed the possibility of a C-section with Alia, assuring her that they would wait for labor to progress naturally. Unfortunately, after giving birth, Alia developed an abscess above the C-section, which she had to address with her doctor who cleaned it and removed the pus from inside.
Questionable Practices Surrounding C-Sections
Doctor M.T., who practices in both private and public hospitals in Damascus, admits that some doctors resort to fabricating indications for C-sections to suit their schedules, as this type of birth offers better financial return compared to natural childbirth. The procedure is also longer and more complex.
In private hospitals, C-sections are sometimes performed even without clear indications, following the mother’s desire. However, Dr. M.T. emphasizes that doctors should educate expectant mothers about the pros and cons of both types of childbirth, allowing them to make informed decisions.
On the other hand, Dr. Nizar points out that public hospitals, like the one he previously worked at, primarily perform C-sections based on genuine medical indications, with few exceptions. Government hospitals often have the advantage of round-the-clock medical staff, providing support to pregnant women throughout the childbirth process, making natural childbirth more accessible.
The Medical Syndicate in Syria acknowledges that specific conditions and indications exist for C-sections. Nevertheless, if both the patient and the doctor agree to a C-section, the doctor may adjust the conditions accordingly. The Syndicate has conducted awareness lectures promoting natural childbirth, but ultimately, the patient’s preference is taken into consideration.
The trend of opting for C-sections, even without genuine medical necessity, has become noticeable in society. While efforts are made to promote natural childbirth, the Syndicate recognizes that patients’ desires ultimately play a significant role in the final decision.
Decoding “C-Section” Indications with Robson’s Classification
In 2015, the World Health Organization (WHO) introduced the Robson Classification, also known as the Ten Group Classification, to standardize the assessment, monitoring, and comparison of C-section rates across healthcare facilities worldwide.The classification system places all women into 10 distinct categories, each exclusive and collectively comprehensive. These categories are determined by five key obstetric characteristics, routinely collected for all mothers, including:ParityNumber of embryosPrevious cesarean sectionsOnset of laborGestational age and fetal appearanceBy adopting the Robson Classification, healthcare facilities can analyze overall C-section rates more effectively, improve their utilization, assess data quality, and increase staff awareness regarding the importance, interpretation, and application of this data.According to Dr. Ahlam, C-section indications are broadly categorized into permanent and emergency cases. Permanent indications encompass conditions like a narrow pelvis in the pregnant woman, breech and transverse priapism (a term for the first-time delivery of a virgin woman).On the other hand, emergency indications involve issues such as defective placental attachment (central placenta), twin presentations in specific situations, and fetal distress during labor, which can lead to a decrease in the baby’s heart rate and potential oxygen deprivation, as explained by Dr. Ahlam.
Lack of Legal Protection for “C-Section” Victims
Syrian law does not adequately address the issue of C-sections and the potential exploitation or negligence of doctors in performing them. There is a lack of clarity regarding the required indications for such surgeries and the need for doctors to fully explain the associated risks to the mother and child beforehand.
Specialized lawyer, Salah El-Din Al-Essa, sheds light on the legal implications of doctors performing C-sections without genuine indications or without obtaining prior consent from the mother. Such practices have been labeled as greedy by some doctors, driven by a desire to increase their income.
Al-Essa points out that the difficulties in “proving cases where a patient underwent a C-section without her consent or knowledge. Even if the patient files a complaint and initiates legal action against the doctor, the case often gets entangled in discussions of medical negligence. Proving greed in such situations becomes particularly challenging because the doctor can argue that the surgery was necessary and successful, and thus the patient may be unjustly labeled as guilty in court.”
Is the Judiciary Favoring Doctors?
In June 2022, Syrian Minister of Justice, Judge Ahmed Al-Sayed, issued a circular to all judges, with a special focus on prosecutors and investigation judges. The circular emphasized the need to carefully observe the specific provisions in the Law on the Syndicate Organization of the Medical Syndicate, particularly when dealing with cases involving medical professionals and potential crimes related to their profession.
The circular stressed the importance of adhering to the principles of prosecuting members of the Medical Syndicate, regardless of whether they had informed the Syndicate or whether the investigations union representative was present during the proceedings.
Furthermore, the Minister of Justice urged the Public Prosecution and investigation judges to seek assistance from specialized collective medical expertise. This measure aims to determine the cause of death or harm attributed to a doctor in the course of their work before any action is taken against them.
Medical Negligence: Uncovering “Misdemeanor” in Childbirth
Lawyer Al-Issa sheds light on a significant gap in Syrian law concerning childbirth procedures, specifically C-sections. The law lacks clear provisions addressing the determinants of a C-section, and it doesn’t categorize it as a medical error. However, if errors occur during the procedure, it can be considered negligence, falling under Article 550 of the Penal Code. Examples include instances of doctor’s greed, neglect of sterilization protocols, or non-compliance with health laws, which all constitute medical errors when they surpass the ordinary standard of care.
Al-Essa defines a medical error as any deviation from the usual and expected medical practice, indicating the need for vigilance and caution.
Article 550 of the Syrian Penal Code generally deals with medical errors, and the Court of Cassation’s jurisprudence has included anything related to medical error under this article, including cases that cause permanent disability.
Testimonies from women like Heba, Alia, Rania, and Bayan, who participated in the investigation, reveal a troubling reality of women undergoing C-sections without medical necessity or prior explanation about the associated risks by doctors. Such practices violate the honor of the medical profession and disregard the well-being of both mothers and babies.
The investigation also highlights the influence of war, economic turmoil, limited awareness, and insufficient oversight in fostering the widespread and uncontrolled use of C-sections. This trend can have long-term consequences, not only on the physical health of women and newborns but also on their mental well-being, leaving deep psychological scars.
Investigation: Raghida Ahmed, Samer Saad (two pseudonyms) / Supervision: Ali Eid
Translated by: Nabil Nabo