Women’s perceptions of caesarean section: reflections from a Turkish teaching hospital

Abstract

Caesarean section as a contentious topic has attracted attention world-wide and different dimensions of the issue has been investigated. The primary reason behind these initiatives have been the upsurge of caesarean sections both in the developed and developing world and the realisation that the operation may not always contribute positively to the mother’s and baby’s health. By contrast, several studies have demonstrated both the short and long term negative effects. Research has also revealed that factors other than medical necessity play an important role in the decision to perform a caesarean section. Turkey, although reliable data does not exist, can be classified among the countries experiencing the caesarean epidemic, at least among highly educated and wealthy mothers. This research, exploring the perceptions of mothers in a teaching hospital with a high caesarean rate, is a rare example of its kind in Turkey. The main finding is the dissatisfaction of the mothers undergoing caesareans during their stay in the hospital.

Introduction

Caesarean section, described as “the most invasive and risk-bearing childbearing technology” (Sakala, 1993) has attracted considerable attention in recent years. The main reason for this emphasis is the upsurge in rates of caesareans around the world. It has been reported that the rates have increased dramatically in countries like the United States (Mutryn, 1993, Stafford, 1990a), Italy (Signorelli et al., 1991) and Australia (Boyce and Todd, 1992). This is not restricted to the developed world. An increase in rates has also been experienced in the developing world: Brazil is a notable example with rates rising from 15% in 1970 to over 30% in 1980 (Barros et al., 1986).

The increase in caesarean section rates has encouraged movements supporting vaginal delivery or “natural childbirth”. Wide-ranging evidence has demonstrated the fact that vaginal delivery is still a very safe option for the majority of women (Francome and Savage, 1993, Sakala, 1993). This view has attracted support from the leading professional organisations for obstetricians. Comparisons between the two methods are made in terms of morbidity and mortality. It has been widely acknowledged that maternal mortality is 2–4 times higher and morbidity 5–10 times higher after a caesarean compared to a vaginal birth (Shearer, 1993, Taffel et al., 1987). There is also a discrepancy in the costs incurred by the two methods. It has been stated that hospital and physician charges for caesarean section are 83% higher than charges for vaginal deliveries (Stafford, 1990a, Hurst and Summey, 1984). When the chronic problem of resource scarcity in the health sector is taken into account, the importance of eliminating unnecessary caesarean section is clear.

Several reasons have been put forward to explain the increase in caesarean sections. Empirical evidence reveals a positive relationship with the patient’s socio–economic status (Barros et al., 1991, Bertollini et al., 1992, Gould et al., 1989, Hurst and Summey, 1984, Sakala, 1993, Signorelli et al., 1991, Shearer, 1993). Detailed analysis of the profiles of patients undergoing caesarean section reveal that private patients (Keeler and Brodie, 1993, Parazzini et al., 1992, Stafford, 1990b) and women with a high educational level (Gould et al., 1989, Hurst and Summey, 1984) are typical candidates for a surgical delivery.

A doctor’s decision whether or not to try a vaginal delivery after a caesarean section in a former pregnancy is an important determinant of the rising caesarean section rates. It is widely acknowledged that vaginal birth after a caesarean section is a safe alternative (McClain, 1990). Shearer (1993) draws attention to the evidence that planned repeat caesarean section provides no benefit to the mother and the baby. Although growing evidence suggests that the “once a caesarean section, always a caesarean section” phrase should be abandoned, a large number of caesarean sections appear to be repeats and doctors continue to be reluctant to try a vaginal delivery. It has been reported that decreased repeat caesarean section played a key role in the dramatic decrease in rates in a teaching hospital (Sanchez-Ramos et al., 1990). The same conclusion was also reached in a survey carried out in California (Stafford, 1990a).

Excessive use of electronic fetal monitoring, although its contribution to the health of the baby and the mother is questionable, and dystocia, a controversial category for emergency section, are also accepted as main reasons for increases in caesarean section rates (Francome and Savage, 1993, Sakala, 1993).

What is the expected harm of increasing caesarean section rates? Apart from the monetary consequences of the operation it also has a negative psychological effect both on the mother and the baby and the family as a whole. Several studies have commented on maternal reactions to caesarean section such as anger, anxiety, feeling guilty, disappointment etc. (Gottlieb and Barret, 1986). Long term negative effects of the operation on the mothers’ physical and psychological state is also discussed (Garel et al., 1990, Cummins et al., 1988, Gottlieb and Barrett, 1986).

So far as the mothers’ situation in Turkey is concerned, some figures can be presented. Maternal mortality rate is considerably high in Turkey (64 in 100 000 in 1995) (Sağlık Bakanlığı, 1997). Table 1 demonstrates information about antenatal care, assistance at delivery and place of delivery by selected variables.

As can be seen from the Table, the type of residence and region are important determinants of place of delivery, assistance at delivery and prenatal care. Women in urban areas and women residing in the West, Central and Northern parts of the country are more likely to deliver at a health facility and hence are more liable to caesarean section. So far as cultural trends are concerned, although there is a lack of research in this area, it can be suggested that caesarean section has become a more prestigious option for women in upper socio–economic classes and of a higher education level. The false assumption that caesarean section is a painless, safer and healthier alternative for delivery seems to prevail among these women.

Although the lack of reliable data is a major handicap in analysing the issue, the authors confidently suggest that caesarean section has become an important phenomenon in Turkey as elsewhere. The rate at the university hospital under study shows that the issue needs attention at least in big cities. However, both because of the idea that delivery is an area reserved for obstetricians and because of the biomedical models that prevail in the health sector (Tatar, 1996, Tatar and Tatar, 1997) the issue has not been questioned in the Turkish context as it has been in other countries. Therefore, the study presented below is important as it could play a critical role in carrying the issue on to the agendas of policy-makers at the macro level and hospital administrators at the micro level. This study aims to analyse the caesarean section phenomenon in a Turkish teaching hospital from the women’s perspective.