IJFAB Blog

Merette Khalil, an Egyptian doula, has spoken out regarding an epidemic of obstetric violence in Egypt’s maternal health system. Khalil cites existing scientific literature which describes obstetric violence as ranging “from the denial of the comfort of a companion of choice, to lack of information about the different procedures performed during care; unnecessary cesarean sections; deprivation of the right to food and walking; routine and repetitive vaginal exams without justification; frequent use of oxytocin to accelerate labor and cutting episiotomies without consent. All these events can ultimately lead to permanent physical, mental and emotional damage.”

Khalil describes her observations of obstetric violence she has witnessed over the years as a doula.

As a doula, I have witnessed almost all of these examples during births, from pushing hard on mama’s abdomen after the baby is born, to mamas being subjected to unnecessary and unannounced vaginal cuts, to being coerced into epidurals or given medication to accelerate labor, without being informed or consenting.

Obstetric violence begins with a lack of education. It begins with telling women that their voices do not have weight during their births compared to the voice of a medical professional.

Obstetric violence starts much earlier in Egypt and in the Region, it starts with the rampant female genital mutilation (FGM) of young girls, to the silencing of adolescents about their sexual reproductive health and rights, to a medical system that continues to see pregnant women as “sick patients” who are not able to make decisions and are not entitled to preferences or information.

Violence can be simple acts of coercion and humiliation- being too intimidated to ask a question out of fear of being shamed, dismissed, or being made to feel stupid for not knowing the answer to a medical question as a first-time-pregnant mom. All too often, many mothers don’t know what questions to ask, or how to get access to the information they need; they just listen to their friends’ or their mothers’ experiences or horror stories, praying it will not happen to them.

Khalil goes on regarding Egyptian hospital policies which require women to give birth in operating rooms, laying on their backs to push. Egypt does not use midwives in hospitals, so health care staff are not trained to deliver babies in any laboring position the woman chooses. Doctors often advise women in advance that they can’t handle the pain of labor and recommend epidurals. Not being able to walk or move while laboring leads to an increase in episiotomies, the use of vacuums or forceps, and c-sections. In fact, Egypt has a c-section rate almost 6x higher than the global recommendation

While women’s labor and delivery choices should be respected, it is important for the ethical principle of autonomy that women have full understanding of all their options. They also must be offered the opportunity to labor in different positions and for labor to progress naturally if that is their choice. This is an international problem as women worldwide often feel pressured in their birthing choices.

After using computer modeling to predict how many cases could occur, Italian researchers from the Bruno Kessler Foundation and Bocconi University believe that voluntary vaccination programs will not be sufficient to contain outbreaks in the years to come. Concerns were raised about vaccination rates in advanced countries including the USA, Ireland, Australia, and the UK.

According to the World Health Organization, 95% vaccination rates are needed to establish herd immunity and prevent a population from a disease. As rates in England have recently fallen to just over 87%, experts argue that the voluntary system needs to be replaced with a compulsory system, although some questioned the effectiveness of compulsory programs.

Lead researcher Dr Stefano Merler said that the UK and other countries would “strongly benefit” from compulsory vaccinations as it would help them reach herd immunity.
But Prof Adam Finn, of the University of Bristol, said there was no proof of this.
“Mandatory immunisation is certainly one way to try and increase coverage but it’s far from clear how well it works or whether it would work at all in many places.
“If the reasons that the vaccine is not getting into the children relate to easy access, vaccine supply or clarity of information available to parents, then making it compulsory will do nothing to alleviate such obstacles.
“If there is widespread mistrust of authority or of the motivation behind any such requirements, it could actually make things worse.”

While the guiding biomedical ethical principle of autonomy generally warrants that competent patients be allowed to refuse unwanted medical procedures, the issue becomes more complex when such a refusal can result in increased risks to public health. Many argue that patient autonomy can be overridden in such circumstances. An additional concern arises in terms of the principle of justice, as those refusing vaccination live in first world countries with access to medical care. But increased cases of measles can affect those living in poorer countries with less access to medical care and fewer resources to deal with an outbreak.

Sally Cheshire, the chairwoman of the Human Fertilisation and Embryology Authority (HFEA), a UK fertility watchdog group, has warned that private IVF clinics are using “selective success rates” to target older women. While the chances of successfully conceiving with IVF are low in general, in women ages 43-44 the procedure only has a 3% success rate, and only a 1% success rate in women over 44.

The watchdog group reported that older women are not being told their realistic chances of success before being sold the treatment. Additionally, some were not being given a realistic cost estimate for all the procedures involved or fully informed of the side effects of the procedures. Some of these women feel desperate to conceive, making them vulnerable to exploitation and more prone to false hope.

Mrs Cheshire said some parts of the sector were using “blatant” sales tactics to persuade “vulnerable” women to undergo treatment.

The 50-year-old said she had even been offered IVF treatments herself, by staff who were unaware of her role with the regulator, at a visit to a fertility show in Manchester.

“We now see things like ‘guaranteed baby or your money back’,” she told the Telegraph.

Mrs Cheshire also called for the watchdog to be given powers to regulate prices, saying that some private centres were charging up to £20,000 for cycles – four times as much as she said treatments should cost.

She said prices were often inflated by the growing use of “add-on treatments”, such as embryo glue and endometrial scratches, offered by clinics to boost chances of success.

Without being fully informed of the risks, chances of success, and costs, informed consent is not being met for these women, making this an evident violation of the basic biomedical principle of autonomy. The fact that the women being deceived are vulnerable makes the practice even more exploitative.