“Giving birth should be as enjoyable, even if a little painful, as pregnancy. It does not have to come with a big ordeal, pain or surgical intervention. We need to rethink our perceptions of pregnancy and delivery,” says Shorouk, the mother of a five-year-old daughter.

It was six years ago that Shorouk, who had been married for less than a year, learned she was pregnant for the first time. “I had no plans for a long wait before having a child. I was in the second half of my 20s and happily married, so getting pregnant towards the end of the first year of marriage sounded right,” she recalled.

What did not sound right, however, was the experience of a cousin who had her first baby a few weeks after Shorouk’s gynaecologist announced the happy news.

“I went to wish her well two days after she left hospital. She was in obvious pain, and she was clearly tired and unable to move comfortably or hold her newborn easily. She had had a Caesarean section giving birth,” Shourouk said.

This was not what she was hoping for in her own delivery. “It was not the first time I had seen a woman who had just given birth or who had gone through a surgical delivery, but because I was in the first weeks of my pregnancy it was particularly discomforting for me to see a woman who was supposed to be happy at being a first-time mother going through so much pain. I decided then that this was not what I wanted,” she said.

Shorouk chose to share her thoughts with her obstetrician. “He was really dismissive. He thought I did not need to think about the delivery, and he said that he would take care of things as they came. I thought that was very condescending. I decided I needed to see another doctor, and I started asking round and going through Facebook groups and websites that dealt with pregnancy and giving birth.”

It was then that Shorouk learned about a doctor whose clinic was not far from her house in Alexandria.

“I went to see Dr Hana. She seemed to have got me right from the first visit to her clinic. I told her that I was willing to put up with pain, but that I did not want to be subject to any surgical intervention that would force me to stay in bed or to go through extensive recovery pains. I also told her that I worried about my shape and that I wanted to keep my body looking beautiful. She understood what I was talking about and promised that we would prepare for a natural birth unless something came up,” Shorouk said.

This preparation turned out to be hard work for Shorouk. “I had to make sure that I ate healthily and exercised regularly. I had to do things that I enjoy and listen to music. I also had to attend courses at a gym given by a natural birth trainer to prepare my body for a natural delivery, and I had a lot of reading to do to understand what my body was going through from the early weeks of pregnancy through delivery and beyond,” she added.

Towards the end of the second week of the ninth month of her pregnancy, Shorouk learned that she would have to go to hospital in anticipation of an imminent delivery. Her obstetrician chose a hospital where there were sufficient rooms equipped for natural birth.

“When I talk about natural birth, I mean a birth in my room not in an operating theatre. This was what I wanted: a natural birth in a well-equipped place under the supervision of a trusted physician that could handle any emergency,” she said.

Upon her admission to hospital and after having gone through basic medical checkups, she met the doula that had worked with her through the last weeks of her pregnancy on breathing techniques and body training for childbirth.

A doula is a birth trainer and companion who does not replace either the obstetrician or the nurse but who helps a pregnant woman go through a natural birth.

“I was very lucky with my doula who had been very well trained. We got along well, and this is as essential as getting along well with the doctor herself,” Shorouk said.

After having been checked by her obstetrician, Shorouk, alone in the room with her husband and the doula, worked through a few types of squats. When Shorouk felt the baby was about to come into the world, the doctor came in with a nurse for another round of monitoring before Shorouk’s daughter Farah was born.

“I cannot say there was zero pain, but it was not the brutal scene of pain I imagined from accounts shared by family and friends. It was exactly the way I wanted it to be. I was aware of everything, and Mohamed [the husband] was with me all the way through. When Farah came, I immediately saw her and held her in my arms while Mohamed with the help of the doctor cut the umbilical cord.”

“All this is a very beautiful memory,” Shorouk said.

Back To Nature

Hana Abul-Qassem is a gynaecologist and obstetrician who insists on helping pregnant women have a natural birth.

“It has been a growing trend all over the world for years, and more and more women are opting for natural births with minimum intervention. More and more women also go through labour and delivery in birth centres rather than hospitals,” Abul-Qassem said.

It was in the 1990s when she was studying in the US that Abul-Qassem did extensive training on the techniques of natural birth.

“Some cases go through a 100 per cent natural birth in their room or their house; some opt for a water birth; and in some cases we opt for what we could call a semi-natural birth whereby the obstetrician intervenes either to enhance the process of labour or to help extract the baby,” Abul-Qassem said.

When a little under 10 years ago she came back to start her campaign for natural birth in Egypt, Abul-Qassem was a pioneering back-to-nature obstetrician in her native Alexandria.

Pregnant women would come to her clinic, but would sometimes be worried by natural births.

“Mothers who often come with pregnant daughters, especially for a first baby, would look un-amused and would say things like, ‘I don’t want my daughter’s life to be put at risk. She needs to give birth in an operating theatre for her safety,’ and so on,” Abul-Qassem recalled.

A decade down the road, Abul-Qassem says she is getting more requests for natural birth options from young mothers-to-be, especially first-time ones.

“I would not say we have a growing trend, as there is still a preference for medicated birth options including Caesarean sections as some women like to think of these as a pain-free birth path,” Abul-Qassem noted.

Research published in the UK medical journal The Lancet in October found that rates of Caesarean sections almost doubled between 2000 and 2015 from 12 to 21 per cent worldwide, with the sometimes life-saving surgery unavailable to many women in poorer countries while often over-used in richer ones.

According to the same research, in at least 15 countries more than 40 per cent of all babies are born by Caesarean section.

Prominent gynaecologist and obstetrician Sherif Hamza argues that for Egypt the rate is around “a little over” 40 per cent. “At times it is the choice of the obstetrician, but many times it is the wish of the pregnant woman herself,” Hamza said.

Several obstetricians who spoke to Al-Ahram Weekly about the situation in government, university and private hospitals agreed with this assessment.

They also agreed that the rate was perhaps a little more in private than in government hospitals due to the financial means that prompt some women to prefer what they think of as a pain-free path.

“It is not exactly pain-free because the pain of recovery from surgery should not be ignored. While of course an able obstetrician should never have a problem with this kind of operation, every surgical intervention comes with a certain risk, so it is our job as obstetricians to encourage women to take the natural path,” Hamza said.

He added that “the assumption that a good delivery has to be pain-free needs to be refuted. Going through labour comes with pain, though of course there are things to be done before and during labour to manage and control the pain. The best thing is always the natural path,” he added.

According to Abul-Qassem, “many Caesarean sections could be averted if women and doctors worked towards a natural birth path. This means that doctors have to take the time to listen to women and to answer their questions and to comfort their fears. It also means that through their pregnancies women have to be carefully examined and followed up by their doctors to make sure that no unpleasant surprises occur.”

She added that while it was true that some women and some doctors simply opt for Caesarean sections to avoid inconvenient birth hours and avert labour pains, it was also true that the failure of some women to go through regular check-ups forced obstetricians to resort to surgical interventions.

Egypt was placed third by The Lancet study in the use of Caesarean sections world wide, with the implication being that these are often unnecessary.

Women's Experiences

Nadia is one woman who opted for a surgical intervention for the birth of her two children.

It was in the early 1990s, she recalls, and “although my doctor suggested I could try to go through regular labour, I opted for the surgical intervention. I did not want to feel anything. I did not want to be one of those women who are left to scream for hours before they are given a Caesarean section. It was simple and fast both times, though it is true that the surgical recovery was not the easiest thing in the world, but it was not so bad either,” she said.

Labour is a process that can take anything from four to 24 hours, Hamza said. Some women panic when the process goes beyond eight hours, and they start fearing complications. Families, he added, also worry for the health of the mother and the expected baby. “Then there are pressures on the doctor to resort to a Caesarean section,” he said.

“A doctor’s job is to comfort his patient and not to force her into anything. I personally much prefer natural birth, but if a patient insists then I have to explain the situation and wait for her decision,” Hamza stated.

Both Hamza and Abul-Qassem agreed that there is a great deal of blame to be put on a lack of awareness for the increase of Caesarean section rates in Egypt.

“Women need to know a lot more about their bodies and about the entire process of pregnancy and birth. They need to talk more with their doctors and their partners, which could help them be less fearful of natural birth,” Abul-Qassem said.

In her early 20s, Habiba is four months pregnant. She is determined that unless she absolutely can’t she will opt for a natural birth. She is currently attending classes at a family wellness centre where she is getting training on muscle management and breathing techniques to prepare for her first natural birth.

Habiba is convinced that going through natural labour allows a woman to “be in control of her body. I know that some women have to go through a Caesarean section, but if it is not mandatory then I would like to be there for my baby when he or she comes out and to be able to hold the baby immediately,” she said.

Hamza agreed that immediate mother-baby contact upon birth is important for both the mother and the newborn.

Sally, in her late 30s, is expecting her third child. Like during the first two she is planning to opt for a 100 per cent natural birth. She has always wanted to avert all medical interventions that deny her a sense of her body or undermine the sense of partnership that she thinks marriage is all about.

“Most women around me opt to have an IUD inserted in their bodies for birth control, and they would not want their husbands to be around when they are going through birth. Most husbands prefer it this way, but this was not the case for me and Mustafa. Right from the beginning, we agreed that marriage was about two people, and this included decisions on family planning options and birth options,” she said.

For her next baby, Sally and Mustafa say they will stick to natural birth. “I must say at moments I get worried for her, but overall I think it is the best choice because I am always with her. I can hold her hand and talk to her, and we see the baby together as it comes into life,” Mustafa said.

This time, the couple is considering a water birth, an option that has only been available in Egypt for a few years by very few doctors.

Hamza is one of the leading names in providing water births. “It is perfectly safe provided that a woman’s condition is normal and that we are not expecting any complications. It is perfectly hygienic, contrary to the fears of some, and it allows a couple to be together while their new baby is coming to life. They can talk and listen to music provided they understand that labour is often a relatively lengthy process,” he said.

Hamza has seen more couples wishing to opt for water births. He thinks it is something that more and more women, usually younger and well acquainted with recent trends, opt for.

Water Births

Over three years ago, Jihan, now in her late 20s, opted for a water birth with Abul-Qassem.

“It was my first pregnancy. I have always loved swimming and I just love water. I spoke to my husband, and he was very supportive, and I travelled from Cairo to Alexandria to meet Abul-Qassem and agree on how to handle the pregnancy in anticipation of the birth,” she recalled.

Jihan had an unexpected early beginning of labour. “It was around one o’clock in the morning when my water broke, about two weeks earlier than anticipated, and I thought I am not going to make it to Alexandria,” she said.

Scared to go through labour on the Desert Road, she and her husband went to the nearest hospital and sought the help of the obstetrician.

“It was an obnoxious experience. He had not even examined me properly before he asked whether I wanted an epidural or full anesthesia. When I said I did not want either, he gave me a very odd look and then turned to a nurse and said, take her to the operating theatre,” Jihan recalled. “I felt like I was a car being taken to a garage rather than a woman going through labour,” she added.

At that point Jihan and her husband decided to go to Alexandria come what may. They called Abul-Qassem, who offered some help, and they drove straight to the hospital.

“It was a matter of an hour or so at the birthing tub before we had Asser, our baby. We both cried and laughed when I was holding him, and Tamer was holding both of us while we were still in the tub,” she recalled.

Jihan said she would opt for a water birth the next time she is having a child.

A water birth is something that a medical midwife can supervise provided that the woman’s condition is good, said Charlotte Caillibot, a Cairo-based midwife.

A mid-wife, in the modern sense of the term, is different from the traditional Egyptian midwife of the early decades of the 20th century. She is also different from a doula because she is medically trained.

“I have a medical degree that requires fewer years of study than a physician’s degree, and it allows me to monitor a safe pregnancy and to refer one that may have complications to a doctor. I help women with no problems go through labour, possibly at home, and follow up on them for the first few weeks after childbirth,” Caillibot said.

Having worked in France for years, Caillibot said that she would not risk providing home-birthing services even for European women in Egypt where this was not licensed.

Ahmed Rashed is another prominent obstetrician. Having worked all over Egypt, Rashed is hesitant about “any unintentional over-promotion of ‘fashionable’ ways of giving birth that might not be compatible with the Egyptian context.”

“When we talk about possible mid-wife assisted births, we are overlooking some key facts,” Rashed argued. He warned that the promotion of resorting to midwives in the absence of medically trained birth assistants could prompt some women, especially in rural and poorer areas, to opt for traditional midwifery services, “which is clearly risky.”

Rashed also warned of the excessive use of doulas “who are said to have been trained abroad without sufficient verification of their training just to serve the new fashion.” He stressed that in a country where the majority of pregnant women fail to receive necessary medical observation, it might not be wise to skip a physician’s help at a well-equipped hospital because “this might have serious complications.”

He is well aware of the “legitimate concern at the overuse of Caesarean sections in Egypt.” But he thinks they should be taken in the context of decreased maternal mortality.

“We have to remember that while in some richer contexts women resort to surgical births to spare themselves the pain, and doctors might resort to it without absolute medical need just for scheduling convenience or even for financial interest, on the wider scale these operations sometimes help to save a mother’s life and maybe a mother’s and a child’s life,” Rashed said.

Caillibot agrees that a wider dependence on home births assisted by midwives is still not an option in Egypt. “It might be the case for some women, but not for all,” she said.

She is currently working on providing information and training courses, on a group and individual basis, for pregnant women who wish to prepare “their minds and bodies for the path of natural birth.”

Giving birth, Caillibot argued, is “not just a physical process, but is also an emotional process. Women are sometimes physically prepared but not psychologically prepared, and this is the job for a midwife rather than an obstetrician,” she said.

More awareness, more availability of obstetricians trained in modern ways of birth, and higher availability of doulas and midwives are said to be necessary for the reduction of Caesarean sections in favour of natural births.

“Giving birth is close to an act of creation. Women used to glorify the body of a pregnant woman and to beautify her for the birth-giving process,” said painter and photographer Salwa Rashad.

She was speaking at the opening of an exhibition of pictures and drawings that glorify women’s bodies, especially through their biological phases. Other art exhibits on display by Noha Nagi and Aliaa Al-Gridi at the Darb 17/18 Gallery earlier this year depicted birth and breastfeeding.

Women, Rashad said, should “cherish and glorify their bodies through every phase, including through the times of reproduction, rather than feeling bad about themselves. This is the message of our exhibition.”

Novelist May Al-Telmessani in her novel Donyazad puts across an equally strong message about women’s celebration of their reproductive functions. She depicts the acts of getting pregnant and of going through birth as intrinsically valuable in themselves.

Speaking about these parts of her novel, Al-Telmessani said that they were like the portrayal of any act in which a woman is heavily involved. “Love, pregnancy and labour. These are part of womanhood. They are part of a woman’s journey, and she has to be an actor in them.”

* A version of this article appears in print in the 13 December, 2018 edition of Al-Ahram Weekly under the headline: Back to natural birth