The Chimera of a Natural Birth in Lebanon

BEIRUT – Last November, on a narrow street in Burj al-Barajneh refugee camp, on the outskirts of Lebanon’s capital, Busra awaited her turn for a postnatal visit at a Doctors Without Borders (Médecins Sans Frontières, or MSF) clinic. Two-month-old Qusayr, asleep in her arms, is her third child. Her two previous deliveries, she said, were “stressful,” while Qusayr’s birth at another clinic — the MSF Birth Center located 10 minutes from the camp — felt different. “Three midwives accompanied me, and they didn’t rush me,” the 23-year-old Syrian refugee explained.

Qusayr was born in an oasis of midwives — a rare scenario in Lebanon, where childbirth care is highly medicalized, dominated by obstetricians in private hospitals that, according to experts in the field, tend to “rush” women into cesarean sections (CS’s, or C-sections).

According to data from the World Health Organization (WHO) shared with Women Under Siege, Lebanon’s CS rate (47.8 percent as of 2018) ranks among the top ten countries globally — far from the WHO’s optimal rate of 10 to 15 percent. That staggering rate likely suggests that many C-sections performed are not medically necessary.

The MSF Birth Center, located at Rafik Hariri University Hospital (RHUH) — the main public hospital in Lebanon — adopts a midwife-led approach and is one of the few places in Lebanon where women are encouraged to have natural birth: its total CS rate stands at 23 percent, according to the Center.

“We encourage women to deliver normally, without interventions like [C-sections], episiotomies, or epidurals because we provide non-medical pain relief,” said Elyse Ibrahim, a midwife with MSF. She’s one of 21 midwives and five obstetricians at the Center, which handles roughly 300 births monthly, often tending to low-risk pregnancies; high-risk ones that require surgery are often referred to other hospitals. In cases of emergencies, they have access to RHUH’s operation room.

In its non-medicalized approach, the Center prepares women to cope with pain via breathing techniques, exercising on a birthing ball, or having a hot shower and receiving a massage or emotional support by a birth companion.

Roughly 80 percent of births (on a global average) are uncomplicated and can be handled by a midwife, while the remaining 20 percent may require an obstetrician, said Tamar Kabakian, associate professor at the American University of Beirut whose research focuses on maternal health. “But that’s not the way care is organized in Lebanon,” she said, alluding to the limited role midwifery plays in Lebanese hospitals. Many private hospitals often do not have midwives staffed, and some of the hospitals that do have midwives employ them instead in the role of assistant to the OB-GYN.

Lebanon’s high CS rate is partly explained by the profit-oriented structure of the country’s healthcare system. About 80 percent of health institutions in Lebanon are private, and hospital fees for C-sections are higher than a normal vaginal delivery, according to experts.

Additionally, C-sections are faster than normal deliveries and can be scheduled. “The convenience of the providers precedes the needs of women,” said Kabakian. “They are not going to wait for her to deliver naturally; they are going to push her toward CS.”

What’s more, she said, most hospitals don’t have written policies related to birth practices, which allows physicians to “stretch” the criteria to encourage a C-section, according to Faysal el-Kak, president of the Federation of Arab Gynecology Obstetrics Societies and director of the Women Integrated Sexual Health Program at the American University of Beirut Medical Center (AUBMC).

For example, some doctors admit women who are in the latent (or early) labor phase of their pregnancies, as opposed to the active labor phase. “If the patient did not start active labor yet, there is no indication [medical reason] to do a CS,” said Christine al-Kady, an obstetrician at the Center. “You cannot say that she even had a trial of labor.”

Dr. Anwar Nassar, chair of AUBMC’s obstetrics and gynecology department, said that private insurances require doctors to justify a medical reason for a C-section, but that’s not the case for patients with public insurance. “They [the Ministry of Public Health] don’t ask why the CS is being done,” Nassar said, criticizing the lack of scrutiny.

In order to control their CS rates, some hospitals, including AUBMC, have established an internal audit system that documents every doctor’s personal CS rate to avoid outliers with unjustifiably high rates. Others, like RHUH, require approval from the OB-GYN chairman to schedule a C-section.

“The Ministry should have a system that would reimburse hospitals based on their CS rate,” Nassar said, a concept that el-Kak agrees with in theory but sees its implementation as far-fetched. “In Lebanon, we have to be realistic,” he said. “Who is going to do the CS review on the hospitals? [C-sections] keep bringing money to the hospital, so they are going to keep it.”

Delivering amid economic collapse

Nassar said that, after counsel, most of his patients opt for vaginal delivery, but he is aware of “some doctors who do not have the time to counsel,” and if the patient wants a C-section, they will just do it. “CS is a higher reimbursement, so that may be a factor,” he said, “especially with this economic situation.”

Lebanon is immersed in one of the worst economic crises today. Since the start of the crisis in 2019, the Lebanese lira (LBP) has lost 90 percent of its value, pushing the population under the poverty line.

Most hospitals are operating at 50-percent capacity, and at least 15 percent of nurses and 40 percent of doctors have left Lebanon last year. Nada Younes, a midwife at RHUH, said that she’s indeed lost 90 percent of the value of her salary since the collapse, and that many of her colleagues struggle to afford transportation to the hospital.

In this crisis, revenue from deliveries is key for hospitals, and C-sections are typically costlier than natural deliveries: a normal vaginal delivery costs between 12 to 33 million LBP (about $8,000 to $22,000, at the official exchange rate), compared to a C-section, which costs anywhere between 20 to 40 million LBP (about $13,000 to $26,000, also at the official rate).

Some medical facilities run by NGOs cover the cost of giving birth, like the MSF Birth Center, where the majority of their patients are Palestinian or Syrian refugees or migrant workers. Since the start of the crisis, however, staff say they are receiving more Lebanese patients, who cannot afford the delivery costs elsewhere.

Generally, public insurance covers 85 percent of the hospital bill, but even meeting 15 percent of the bill is out of reach for many. The minimum monthly wage equates to about $30 today. Additionally, many women cannot afford an epidural — the most popular method of pain relief during labor, which costs anywhere from 500,000 to 6 million LBP (between $333 and $4,000, at the official rate) and is not covered by public insurance. Younes said that, at RHUH, less than five percent of patients can actually afford the cost of an epidural. “The rest just take painkillers.”

A foreign concept

“A woman in pain who is denied an epidural because she has no money — that’s systemic violence,” said el-Kak. “It goes against universal health coverage with dignity and quality.”

The term “obstetric violence,” which largely refers to “the abuse and mistreatment of women during the provision of maternal healthcare,” was coined by Latin American activists in the ’90s. Since then, several countries — in that region particularly, like Argentina, Venezuela, and Uruguay — have included the term in legislation, but it remains a “foreign” one in Lebanon, explained Kabakian, even among women who’ve suffered it.

At 39 weeks, Marleine, a social worker in Beirut, received a phone call from her obstetrician at a private hospital asking her to come in. “They induced me for labor,” she said. Every 15 minutes, a nurse would enter to perform a cervical check. Three hours later, she had a C-section at the doctor’s insistence. “I was uncomfortable, I started crying,” she said. “It all happened so fast, I didn’t feel supported to go for natural birth.”

Fifty kilometers away, in the heart of the Bekaa Valley, 34-year-old Sara* had a near-identical experience when, at 39 weeks, she was also instructed to check into her hospital. She felt reluctant because she didn’t feel contractions and her cervix was only dilated by a centimeter (she knew her cervix should be five centimeters to be considered in “active labor”), but her doctor insisted it was “risky” to wait.

Sara was induced, and a few hours later, she was told to prepare for a C-section. “I told the doctor we could wait,” she said. “I felt like he was pushing me.” Still, she trusted him.

“If your doctor tells you there is a risk, what can I do?” she said. “It felt like emotional abuse.”

In her work, Sara often educates about abuse of power, but after her experience delivering, she said she felt guilty for not standing up for herself.

In Lebanon, it remains that few women, like Marleine and Sara, are as well supported as Busra was to make independent decisions around their labor, and spaces to give birth in a pressure-free environment are few and far between. In a collapsing economy, the country’s pregnant women are left to fend for themselves in a privatized and medicalized system that’s willing to sacrifice women’s bodily autonomy for profit.

*Names of individuals have been changed for privacy reasons.