Caesarean section (c-section) rates are high across the Middle East. This varies massively according to wealth, education and urban/rural locations, but it is undeniable that many are drifting towards the procedure, especially in GCC countries. Experts are now voicing their concerns about this surgery, with a high number of doctors saying that educating Omani women about c-sections is the key to discouraging unnecessary surgical births.

Technically, there is no reason to avoid undergoing a c-section, but most medical professionals would prefer to see it reserved for medically necessary procedures, in order to tip the balance in favour of natural childbirths.

In early 2017, Dr Tamima Rashid al- Dughaishi, senior consultant in maternal foetal medicine and president of the Omani Society of Obstetrics, said c-sections can save lives when needed. She added that if the procedure is performed unnecessarily, it can put women and their babies at risk of short and long-term health problems.

According to data collected by institutions under Oman’s Ministry of Health, c-sections accounted for 19.6% of all the deliveries in 2013. The same year saw the number of deliveries reach 66,557; 11,822 of these were c-sections.

In 2015, a study conducted by Sultan Qaboos University in Oman found that the most common reasons cited for this surgery were foetal distress, non-reassuring foetal heart rate or dystocia, which is also known as obstructed labour. Other conditions included antepartum haemorrhage, where bleeding occurs from the 24th week of pregnancy; severe pre-eclampsia, which is a disorder characterised by high blood pressure and a large amount of protein in an expectant mother’s urine; and foetal macrosomia – a term to describe a child with an excessive birth weight.

The Omani Ministry of Health’s statistics show that 27% of c-sections were elective and around 73% were for emergencies in 2013.

A different study called ‘Obstetric and Non-Obstetric Risk Factors for Caesarean Section in Oman’ aimed to explore the risk factors, profiles and neonatal outcomes of c-sections among selected Omani women in 2012. This research called for more awareness about clinical and public health factors that could prevent the risks linked to conditions associated with c-sections, such as maintaining a normal BMI, and preventing gestational and type 2 diabetes.

WHO has stated that having a c-section rate that is greater than 10–15% is unnecessary, regardless of location. This raises a key question – could GCC women be opting to have the procedure for cosmetic reasons? Dughaishi notes that this creates an issue, as risks to the mother during a c-section include excess bleeding, as well as a wound or womb lining infection, which causes a fever, womb pain and abnormal discharge.

Cultural change

A substantial amount of research into c-sections has been conducted in Oman, where it is simultaneously causing the most alarm among health professionals – even with the country’s figures falling below the UAE’s. The Omani Ministry of Health’s statistics show that 27% of c-sections were elective and around 73% were for emergencies in 2013.

When speaking to the Times of Oman, Dughaishi stated that the number of c-sections has increased over the past few years in Oman, but this hike has not been as steep compared with other countries. She attributed this growth to a number of reasons, including an increased birth rate; more complex cases arising out of lifestyle-related health issues, such as diabetes, hypertension and obesity; and the fact that women who have undergone a c-section are more likely to have another for future pregnancies.

On the other hand, Dughaishi affirmed that the number of women who demand a c-section is not very significant in Oman, as the country still favours natural childbirth.

She states that mothers educate their daughters about delivering naturally in Omani culture, and Dughaishi believes that this is a good thing, as families tend to be quite large, which leads to women having multiple natural childbirths.

Concerns in the UAE

In Oman, the figures should be measured but there is no cause for real concern; however, the same cannot be said for the UAE. There has been a surge in c-sections, particularly in Dubai. Statistics published in 2016 reported that there were 12,055 births via c-section in 2014, with 15,756 natural births in the region.

Almost 50% of all deliveries in the UAE are c-sections, according to Gulf News. The newspaper spoke to Dr Vaishali Srinivas Joshi, a specialist obstetrician and gynaecologist from Primacare Speciality Clinic in Dubai. She said that a c-section should not be offered to pregnant women, unless it is needed. “These days, many women are requesting elective c-sections because they have anxieties about having a natural birth for the first time. They are often afraid of labour pain and the effects of labour on the pelvic floor,” she explained.

Some studies have found that women who have had one or more procedures have a higher risk of infertility and ectopic pregnancy.

However, the uptick in c-sections can also be attributed to changes in age and maternal health. “Overall, pregnant women have become older and heavier, and are more likely to undergo c-sections more often,” said Dr Rashi Gupta, a specialist in obstetrics and gynaecology at iCARE Clinics, which has multiple centres across Dubai.

She mirrors Omani concerns that post-operation monitoring can sometimes be lax, resulting in poor wound care. “Having a c-section also increases a woman’s risk for more physical complaints following delivery, such as pain at the site of the incision and longer-lasting soreness,” she added.

Caution not panic

Dughaishi spoke about the risks of having a c-section for the baby and the mother during the birth and later in life. She said that the procedure is performed under local or general anaesthesia, which may have some associated risks, such as anaphylaxis, a serious allergic reaction. Nearly all c-sections are completed safely, but they are still serious operations. Other worries concerning post-operative care should also be considered. “There is always a risk of blood clots happening in the legs, which can be dangerous if part of the clot breaks off and travels to the lungs,” she explained.

Damage to the bladder or the tube that connects it to the kidney is another risk that could require further surgery, she added. Dughaishi also said that women who have had c-sections for two previous pregnancies are more likely to have the procedure again for others. However, having one or more operations increases the risk of developing complications for future pregnancies, which is something that could be avoided by having a natural birth first time.

Dughaishi stated that some studies have found that women who have had one or more procedures have a higher risk of infertility and ectopic pregnancy, where a fertilised egg implants itself outside the womb.

When asked if women are more likely to die during a c-section than a natural birth, Dughaishi concluded that problems can arise in any birthing incident, but some studies have shown that the operation does increase the risk of pregnancy-related death.

Considering the risks of c-sections, natural delivery could benefit expectant mothers. Its advantages include quick recovery, a shorter hospital stay, and the added reassurance of no scarring and similar, safer deliveries in the future.

As the trend for undergoing unneeded caesareans continues to rise in GCC countries, so do debates about their medical issues. Many doctors are concerned about the procedure’s growing popularity, and it is even more concerning that some women may not receive effective postoperative care, due to regulatory issues in the region’s healthcare system.