On giving birth: Our bodies as vehicles and our bodies as agents

Editors’ note: This piece is part of a series on gender and labor. If you would like to pitch for this series, please write to [email protected].

Egypt has one of the highest rates of cesarean section births in the world, at about 67 percent of hospital-based births, according to a study by the Population Council. Their research indicates that the rate is only increasing. 

A few alarming headlines in recent years have described this as medical butchery, suggesting that it is due to doctors’ economic interests, or to women (and, interestingly, their seemingly ever-present mothers) electing for c-section births. 

The medicalization of childbirth in Egypt has brought infant and maternal mortality rates down but it has made no room for childbirth to occur naturally, a process which - especially for first-time laborers - is unpredictable and requires support for potentially many long hours. However, experts resoundingly agree that, when it can be done safely, it is healthier for the mother in terms of her recovery and future pregnancies, as well as for the child being born. Today, natural birth and medical birth are pitted against each other because the healthcare system does not integrate both —  it doesn’t allow for medical supervision that supports natural birth by providing midwifery services, classes on childbirth or training nursing staff in how to support the process. 

What does this mean for pregnant women, and for our reproductive futures as individuals and as a society? 

***

A few months into my pregnancy, I noticed that the veins on the backs of my hands had gotten larger and bulged out more. I discovered that my body was producing about 150 percent more blood than usual in order to build both the baby and the placenta.

I’m not sure I knew what a placenta really was before I was pregnant. But I’m sure that in month three, I found out that the mild nausea and the unnegotiable tiredness I’d been feeling in the first trimester was because of the energy I was exerting — not to grow the fetus, but to make the placenta, an entirely new organ that carries blood and nutrients to the baby, and funnels waste away from it.  

Much of pregnancy was like this: a process that was happening at my center, but somehow independently and without my conscious direction. There was an innate distance between myself and this invisible, intimate transformation. 

After we watched in disbelief as the baby’s measurements were taken during a 20-week scan — here are legs, here is a head, here is a mouth, here are fingers — I began to read and to ask about childbirth. Millions of women give birth each year; it is an everyday occurrence. Yet I had no knowledge of how to get through it. It all had to be acquired. 

The more I learned about what my body was doing to make this new life, the more I wanted to collaborate with it. The work my reproductive system had been doing since puberty — the monthly periods with their pain and hormonal changes — was a necessary part of what it was undertaking now: the muscular stretching, the practice contractions. I hadn’t had any complications during the pregnancy, and while I still could not imagine how childbirth would actually work, part of me was curious to see what the end — the climax — of this process, and the beginning of so much else, would be like. 

I found myself in deeply polarized territory. On the one hand, an international movement towards natural, drug-free birth which has spread in some parts of the world has also begun in Egypt, although it remains niche and very class-limited. On the other, the mainstream approach to birth in the private sector is dominated by the cesarean section. 

After a checkup at the beginning of the last trimester, as I was buttoning up my maternity blouse, I asked my doctor if we could talk about the birth and what to expect from it.

I told him I wanted to try and labor without an epidural, which, in addition to being immobilizing, prolongs labor and increases the chances of delivering by c-section.

He had said he had time to talk but I still felt like I was cornering him, aware of the half dozen women in the waiting room, his more-than-usual briskness.   

He was adamant that I would be unable to manage a natural birth.

“You can try,” he said. “But it’s the second-worst kind of pain after a total body burn.” 

How did he know what the pain would be like? Or how I would react to it? I didn’t reply then, but I noticed the panic on my partner’s face. 

Instead of medical caregiving me more options and a sense of safety, I felt like I was being pushed towards interventions I didn’t want, and a cesarean section there was no need for. 

Soon afterward, I switched to a doctor who was more willing to support a so-called natural birth, but what remained with me was the sense that I was on the back foot. For months, whenever someone asked why I wanted a natural birth, I found myself speaking with long preambles, like I had to justify my decision as something that was aberrant, against the norm. 

***

One woman I interviewed says that in the last months of her pregnancy, more than one person asked her “When’s your operation?” instead of “When is the baby due?”

Egypt’s spike in cesarean births — reaching about 52 percent of total births — is part of a global trend. A worldwide study released by The Lancet medical journal in 2018 found that c-section births doubled from 12 to 21 percent between 2000 and 2015. The study describes the increase as alarming and warns that it is detrimental to the health of women and babies. The World Health Organization says that c-sections should only be performed when medically indicated, which they estimate to be the case in between 10 and 15 percent of births. 

Although there are variations, the prevalence of cesarean births in Egypt cuts across class and geography. Data shows that in urban governorates they are at 62 percent and in rural areas, 48 percent. The more educated a woman is, the more likely she is to have a cesarean section, but even among women with no formal education, the rate is at a high 37 percent. 

The frequency of cesarean sections has made them seem casual. “My sister gave birth by cesarean section, my two best friends did also,” one woman tells me. “All the births around me were c-section births. When I got pregnant, I just assumed that’s what I would do.”

Women I spoke with who delivered in private facilities describe feeling pressured into choosing cesarean sections in various ways: doctors told them that they would not be able to handle the pain. They told them that a vaginal birth would “ruin sex.” They told them that cesareans were safer.  

While rates of cesarean birth are slightly lower in public hospitals, they are still high, at about 55 percent. Research by the Population Council suggests several contributing factors: there are few available pain relief options to be administered during labor, cases are handed over from one doctor to the next as shifts change, and doctors are sometimes afraid that complications may arise during vaginal birth. News reports from 2018 quote the Health Ministry as saying that doctors are not adequately trained to deliver vaginally.  

Surgical training may also be an incentive for cesareans in public teaching hospitals, Amr al-Noury, an OB-GYN and former head of the Royal College of Obstetricians in Egypt, says. “At the same time, there is no use of forceps or vacuums, which are used to assist 10-12 percent of births in other places.” These instruments, used to assist vaginal labor, have become very safe but have dropped out of surgical practice in Egypt as doctors have relied on c-sections more and more. The Royal College is making an effort to reintroduce them by running workshops to train doctors on their use. 

On admission to public hospitals, women are sometimes separated from their families in the labor ward, according to Noury. This deprives them of personal support as they labor, as well as people to act as their advocates within the hospital, making their chances of successfully delivering vaginally lower. 

In the private sector, common explanations of c-section rates include that doctors are profiteering, since sometimes they charge more for c-sections, or that they want to save time and effort by scheduling c-sections, which can take between 30 and 45 minutes, rather than overseeing natural labor with its unknown and unpredictable schedule. Karim Zaky, an obstetrician known to support natural births, points out that natural deliveries in hospitals require more staff, more time, and more expertise than cesarean sections. 

We think of c-section as a hypermodern practice, but it has long been a part of human birth. It predates the birth of Julius Cesar, who is said to have been named for an ancestor who was born this way. Although I came across some references to living women giving birth by cesarean section in ancient China, it seems that before the invention of penicillin and anesthesia, the operation was usually performed to remove a fetus when its mother was dying or had already died. 

Today cesarean sections are usually performed in medical theaters with partial anesthesia or an epidural so that the mother feels no pain but is awake during the operation. 

A cut is made to the abdomen and a second one to the uterus. Basma had an unplanned cesarean section. The doctor, she says, “walked me through everything he was going to do: cleaning the site of incision, making the first incision, then more incisions through different layers, always asking me if I was ready or if it was ok.”

“There was the moving around of organs, what I might expect to feel — tugging, pulling, waiting. It reminded me of having my four wisdom teeth surgically removed from beneath the gums when I was 19 — I guess I have a history with having things pulled out that don't want to come out naturally.” After the baby and the placenta are birthed, the cuts are sewn back up.

A cesarean section can be a life-saving operation when certain complications arise: hypertension, the baby or mother in distress, or obstructed labor. 

It’s the most common major surgery in the world and is a relatively safe operation. But it does carry risks of complications from anesthesia as well as increased chances of pulmonary embolisms and infection. There are also increased chances of complications in future pregnancies: the placenta can lodge itself in the wrong place in the womb and the uterus can rupture. Importantly, delivering one baby by cesarean section increases the chances that future pregnancies will also be delivered the same way. (Women’s ability to deliver vaginally after cesarean sections, known as VBAC, varies greatly from one place to another, as healthcare systems offer different levels of expertise and support. The UK, for example, is known to be supportive of VBACs, while Egypt is not.)

The recovery period from cesarean births is longer, and more painful than natural births. All of the women I spoke with, including those who chose to have their c-sections in advance, say they were underprepared for how difficult the recovery would be.

C-section births have also long been associated with higher rates of postpartum depression and difficulties breastfeeding. 

For newborns, cesarean births have been linked with higher chances of developing allergies and higher risks of obesity. 

“Labor is a process that the body spends a long time getting ready for, and it can go on for hours, or for days,” Sawsan Mustafa, a Cairo-based childbirth educator and doula, says. “During that time, the body’s hormones start to prepare it for the birth and its aftermath — for breastfeeding, for recovery, for bonding. C-sections are a shock to the system — the body doesn’t have a chance to prepare.”

***

Amany, who delivered in a private hospital, believes she was tricked into a cesarean section. “We had agreed on a vaginal birth. At first, it was all calm and unhurried, and the doctor was following up with me by phone. After 12 hours of labor, I checked into the hospital. I was nearly fully dilated. I was hooked up to an epidural, and a heart-rate monitor. Then I went into the labor room and everything suddenly changed. The doctor took my husband out of the room and told him we were in danger, that they should do a c-section. He didn’t tell me this, he didn’t tell me anything other than that if I started pushing the baby would be in distress.

This was around 6 pm. Later I found out that he had clinic hours at 7. I believe it was set up ahead of time, that he planned to go for a c-section all along. I felt totally betrayed.”

As the data shows, the problem extends far beyond the kind of emergency scenario Amany describes, although the doctor’s communication of the emergency to her husband rather than to her is also representative of a tendency to objectify women in labor. The problem is systemic, and it is creating a future in which women have less and less control over the births which they’ve already spent months of pregnancy laboring towards. The question, and the beginning of its answer, is not what choices women are making, but why. 

In the absence of prenatal classes, midwifery and other forms of support and information, most women in Egypt will rely solely on an obstetrician not only during birth but for consultation throughout their pregnancy. They will want that particular obstetrician to be with them throughout their labor and delivery.

The culture of over-reliance on a single chosen doctor within the private medical field based on his or her reputation cuts across fields and specialties. A weak healthcare system has shaped a private market anchored not by hospitals, group practices, or clinics, but by individual doctors.

“There is great pressure on a doctor’s time. He has a clinic, he has other cases,” OB-GYN Hussein Gohar says.  

“Definitely people are taking shortcuts. Definitely, when women come and say they want a c-section because they are afraid of the pain, some doctors will just do it just to save their time.”

One after another, each doctor I spoke with tells me that they are doing more than their job, which should traditionally be the work of a midwife. 

A midwife’s job is to support and guide women throughout labor, ultimately helping to deliver the baby. In places where midwives are part of the healthcare system, like the UK, they are trained to catch babies in any position, they can administer some pain relief, they cut the umbilical cord and can use instruments such as forceps to assist in the birth. 

The absence of a midwifery system in some parts of the world is one of the reasons the Lancet study credits for the rise in c-section rates.

Egypt does not have a midwifery system. A school of midwifery, attached to what is now Qasr al-Aini Hospital, was started under Mohamed Ali at the direction of the French doctor Clot Bey. According to scholar Khaled Fahmy, the school’s purpose was not to improve public health, but to serve the state’s military interests by improving the sexual health of officers and their wives and to improve infant mortality rates. The school never became very big; the maximum number of midwives, called hakimat, working there at any given time was around 60, according to Fahmy. The school later suffered during the British occupation,* and seems to have eventually closed in the late 19th century. 

The obstetricians I spoke with — two of whom had trained with the UK’s National Health Service, which relies heavily on midwifery — lament its absence. 

Doctors are trained to see pregnancy as a set of problems. “As a doctor, I look at a pregnant woman and I want to remove the pregnancy,” OB-GYN Hanna Kassem, who runs a natural birthing clinic in Alexandria, says.  “Midwives have a different approach.”

Midwives have disappeared from the official healthcare system. In some poorer and rural areas, a daya, who can be described as a traditional lay midwife, helps deliver babies, but the healthcare system does not recognize or regulate midwifery of any kind. 

Doulas are not medically qualified in the way that midwives can be, but they do support women through labor and can serve as their advocates. 

I knew I wanted Sawsan, the doula and birth educator quoted earlier, with me during my labor from one particular moment during our first meeting. I was about eight months pregnant and full of questions, anxious for support. She was talking to me about different patterns of contractions and how they work, and to demonstrate she wrapped her hand around my upper arm and squeezed. It was a small, intelligent communication but it worked instantly. She had been through it, she had studied it, and she knew how to thoughtfully guide other women through it. I also liked that she spoke to the unborn baby’s father directly and engaged him seriously. Outside of obstetrics, men have not historically been part of labor, but more and more want to be. 

I was able to pay to take Sawsan’s classes and to have her with me. As access to this kind of support is becoming more and more circumscribed by class, a chain of information and support between women about birth is being lost. 

“Women are in a situation in which they have to try very hard to seek out the information they need from a class or a doula … we need to spread the knowledge about this. If there were a midwifery system in Egypt — which would take a long time and would be met with great resistance — it would make a great difference,” Noury says. 

***

“Natural birth cannot happen if the mother doesn’t have information,” Kassem says. 

In 2013, Kassem opened a birthing center in Alexandria that focuses on natural birth and also supports pregnant women by running prenatal classes and breastfeeding support.

She started out giving childbirth education courses in a rented space within a hospital, but then she wanted to expand and one of her goals was to do so in an environment that didn’t make women feel like they were “sick patients” just because they were pregnant, she says.  

Kassem’s clinic is part of a small but growing movement towards natural birth in Egypt, although it remains accessible only to the educated middle or even upper classes. Doulas and midwives have started offering their services online, and a few obstetricians have begun building their reputations as doctors who are supportive of natural births.

Within natural birth literature and discourse, there can be a sense of judgment around the choice to take painkillers or to choose c-sections, which are sometimes misrepresented as passive and less worthy than natural births, or even as less of a birth. 

Some advocates and midwives make a point of preparing women for the possibility of a cesarean section birth, but overall the discourse can treat and dismiss c-sections as a “non-event” — strangely mirroring the mainstream cultural branding around the surgery as a standardized, simple experience. Basma, quoted earlier, had no idea what to expect from the surgery because, as she planned for her birth, none of the literature she read prepared her for a c-section. She had a doula with her through the surgery who “kept whispering encouraging things, making jokes, saying I was doing great. I realized then that my body was still being depended on to perform. To do good.”

But at its core, the natural birth movement is about bringing agency to pregnant women, whatever kind of birth they end up having. It’s about allowing them to be active and informed participants in childbirth. Information itself is understood to be the main deterrent to panic and fear: Women know more about what to expect from labor, learn ways of working through contractions (such as breathing exercises, as well as different movements and positions to help the baby descend into the birth canal while also relieving pain), and are encouraged to involve equally informed birthing coaches, be they doulas, partners, or friends. 

Even with a doctor who is supportive of natural birth, trying to have one in a hospital is awkward at best, and a direct conflict of interest at worst. Most hospital procedures stipulate that women labor in bed and on their backs — the most painful position a laboring person can be in during contractions, and one which denies her the benefit of gravity. 

Labor happens in stages. The cervix — the passageway between the uterus and the vagina — spends hours, sometimes days, thinning, moving, and opening up so that by the time the fetus is ready to be born it can be pushed by the contractions of the uterus into the vaginal opening, and finally outside of the body.  By the time this is happening, the cervix, which has spent months plugged shut to keep the uterus closed, has moved itself out of the way.

The fetus tucks its head inwards, so that the smallest point of its skull, which is still soft, is the first out. This is why many babies born vaginally have elongated, cone-shaped skulls for the first few weeks of their lives. 

Throughout the withdrawal of the cervix, called effacement and dilation, the body moves into active labor. Contractions become longer, more frequent and more painful.

It’s towards the end of this period, before feeling the urge to push, that many women report a feeling of despair. It feels like it will never end; they are not sure if they can do it; they are worried about the baby who doesn’t seem to be coming. Natural birth advocates say that this is the point at which women laboring in hospitals become particularly vulnerable to unnecessary medical interventions. One intervention leads to another, a pattern referred to as a cascade. More often than not, according to the experts I spoke with, the cascade ends with a cesarean section.

Halfway through the pregnancy, the bones in my feet hurt, bones I had never been particularly aware of. They were stretching, rearranging themselves to adjust to a new center of gravity. As the baby grew and my gait changed, people asked about my birth plans and whether I was scared. I was. 

A friend was perplexed by my decision to avoid the epidural. “Why would you go through pain you don’t need to go through?”

An epidural is administered via a needle in the spine, and this in itself made me nervous. It is the most effective pain relief for contractions. It also prolongs labor and increases the chances of a c-section. 

More importantly, it makes a woman immobile, and totally reliant on the doctor and hospital staff. This means that, when it comes time to push, she will have to do so on her back without the benefit of gravity. This increases her chances of an episiotomy —  a surgical cut made to her perineum to widen the vaginal opening and allow the head to come through. 

Episiotomies are not meant to be routine practices; medicine in other parts of the world has left them behind. But in Egypt they are still routine — the idea being that without them, women would tear, and that healing from a tear will be more painful and dangerous than from a surgical cut. There is not much data on episiotomy rates in the country, but they are almost expected. 

“Vaginal birth has come to mean having an episiotomy, and this makes women hate it. It shouldn’t be routine, but it is,” Kassem says. 

“It was either I get sliced open in my stomach for a c-section or I get sliced open down there,” one woman tells me. 

“Doctors aren’t evil,” Sawsan says. “This is what they know. They never see a natural birth: a birth that happens upright, without episiotomies.” 

***

For all of my desire to resist intervention as best as I could, I did not want to deprive myself of the option of medical assistance in case of complications. The vast majority of women in Egypt make the same choice. As labor progressed, the hospital staff — nurses, shift doctors and the doctor who examined me on admission — seemed increasingly bewildered and flustered by my choice. After the birth was safely over, two of them asked me why I had “done this to myself.” The doctor who had examined me on admission, and given me a thumbs up on my birth plan, came to the head of the bed and asked: “Why didn’t you take the epidural or have an operation?” She didn’t wait for me to answer before walking away. 

Doctors often accuse doulas and midwives of being quack scientists, troublemakers who question their authority in hospitals and labor wards. Natural birth advocates accuse doctors of obstetric violence: of intervening in women’s labors and bodies unnecessarily and without their consent. But everyone agrees on the fundamentals: that the rate of cesareans is too high, that doctors should not be a pregnant and/or laboring woman’s only resource and support, and that these two points are connected. 

For most women in the country, there is no choice. To benefit from the safety of medical attention — of prenatal care, and of intervention and assistance when necessary — women have to rely on doctors. Fewer women and babies are dying, but what kind of births are they having? Does it have to be all or nothing — either a total loss of agency, or the risk of a medically unsupervised birth? What are the potentials for reintroducing midwifery to the healthcare system in a way that this time is explicitly about public health? 

It is too soon to tell whether the nascent natural labor movement will expand beyond its class boundaries, whether a culture of women guiding and supporting other women through labor will make a return, and whether the information and classes will be accessible to more people. 

“It’s hard for doctors to change how they do things,” Kassem says. “The change has to come from below. Mothers will push doctors to change their practices over time. We are seeing doctors now being asked about water births, about totally natural births.”

*La Verne Kuhnke, Lives at Risk: Public Health in 19th Century Egypt.