At the early hours of dawn late last June, Jehad felt the contractions signalling the birth of her first child. Coming earlier than expected, these contractions left her and her husband, Ahmed, in a fix. “We had not decided where I would go to give birth and, on that day, we were not sure what to do,” she said.
Medical fees and apprehension had left the couple undecided about whether Jehad would go into labour at a private hospital with the physician who had been following her pregnancy or at a public hospital. Despite the fact that the couple had stable jobs as civil servants, they felt too intimidated by the fees required by the obstetrician.
“It is not that we were not aware of the levels of medical fees for obstetricians and private hospitals; it is just that we did not have enough to cover the doctor’s [indicated] fees and the anticipated hospital bills,” Ahmed said.
Jehad was keen to avoid giving birth at a public hospital. “What I heard from family and friends and people around me about the treatment women get when they go through labour did not sound very encouraging, to be honest,” Jehad said. She explained that friends and relatives generally shared experiences of impatient obstetricians who were very inattentive to the feelings and concerns of the women. “I was scared but, at the same time, we did not have the money to go to a private hospital,” she said.
Living in Al-Mounira, not very far from Al-Qasr El-Einy – the hospital associated with the Cairo University Faculty of Medicine – the couple decided to rush to the emergency room there, especially as the contractions were becoming very painful.
As she stepped into Al-Qasr El-Einy, Jehad was “very scared”. She said she could not stop thinking about the complaints she had been following on social media from women who had dreadful experiences giving birth in public hospitals. She was not aware of any difference between public and university hospitals – at least not according to the experiences that were being shared on social media towards the end of June.
“By the time we arrived, Jehad was immediately rushed into the labour room and, luckily, it was an easy labour and it did not take long for her to give birth to Mohamed, our first child,” Ahmed said.
The experience, Jehad said, was “not bad overall”.
“I was scared, my husband was not with me, my mother had not arrived by the time I was actually going into labour and I was helped by a male doctor whom I was meeting for the first time – and I am not sure he really knew my name; he just kept calling me ‘mama’, as he did with other women going through labour,” she said.
What made the couple very happy, however, was the fact that she did not need a caesarean section, contrary to the assessment of the obstetrician Jehad had been visiting during her pregnancy. This natural childbirth, which went smoothly and quickly, left Jehad and Ahmed uncertain about what to think of the obstetrician. “I am not sure if he recommended an operation because he really thought she needed it or not. And if he really thought she needed the operation, then what does this mean? One is not sure what to think,” Ahmed said.
According to Mohamed El-Hodaiby, a consultant in gynecology and obstetrics, the answer to such and other related questions starts with recalling the definition of a good medical consultation. He argued that there are three things that a physician needs to meet to fit the bill of offering good medical consultation and sound advice. A physician, he said, needs to be technically capable, ethically correct, and equipped with the required communication skills.
A well-trained and skilled physician, El-Hodaiby argued, is not good enough on their own. Ethics, he stressed, are essential “because when the doctor discusses with his patient a decision that involves money, the doctor needs to firmly refrain from any calculations of money-making for his own interest,” he said.
Equally, he added, if a doctor lacks the required communication skills, he would fail to pass the message to the patient and consequently fail to help the patient think clearly and make an informed decision. “Adequate communication skills should allow the doctor to show empathy while respecting the patient’s privacy and to offer advice without compromising the patient’s autonomy,” he stated.
The absence of any of these three elements would immediately compromise the consultation process, El-Hodaiby said. Based on his close to 20 years of practice in England, El-Hodaiby is convinced that securing quality medical consultation cannot be left to individuals’ good intentions. “There has to be a system to secure that such requirements are observed,” he said.
Back in Egypt to restart his career, El-Hodaiby is convinced that the issue does not really relate to public medical service as opposed to private medical service but rather to the norms of the doctor-patient relationship, which vary from one set-up to another, both within the private and public medical contexts.
Clearly, he said, it is not enough to train physicians to deal with difficult situations, manage emergencies, or even break bad news when they inevitably occur. It is also important to make sure that doctors are not overworked, that they work under the right conditions, and that they receive proper appraisals.
El-Hodaiby said that anywhere in the world, it is not unusual for patriarchy and hierarchy to be present in the doctor-patient relationship. However, what keeps these tendencies in check is a system that provides clear criteria for engagement, secures the empowerment of the patient, the appraisal of the physician, and offers regulatory oversight.
In actual practice, he explained, these criteria mean that a patient should get sufficient time to discuss all her concerns with her doctor and that the doctor should be attentive, because concerns vary from one patient to another, and offer solutions to help the patient make her own decision.
“When I tell my patient that she needs to have a caesarean section, I have to explain to her why I think this is the right medical decision,” he said. Moreover, he added, “when one of my patients who had previous traumatic caesareans, while living overseas, requested a natural birth with a third pregnancy, I had to candidly explain to her the chances, the risks and possible scenarios; then it becomes her decision.”
Al-Hodaiby is hopeful that, along with the Physicians Syndicate, the Egyptian Health Council (EHC) would have a firm role in setting clear guidelines, “with a clear mechanism of application”, to secure a good experience for both doctors and patients. He is also hopeful that, in this process, there would be a mechanism to reflect patients' voices and concerns.
Established in 2022, the EHC has a mandate to regulate medical practice in Egypt. This includes establishing medical training and guidelines for practice. Moutafa Abbas, assistant professor of gynecology and obstetrics at Ain Shams University, sits on a committee of around 20 members entrusted with working out the guidelines for training and practice for gynecologists and obstetricians. “We have been working for a few years now and we are not done yet, but we have made considerable progress,” Abbas said.
What makes the task challenging, he said, is the fact that the creation of the guidelines is designed to apply across the spectrum of all medical facilities without discrimination. He explained that the reality on the ground is rather complex because not all medical facilities are equipped in the same way – and this discrepancy is only one of many issues that include everything from the size of the medical staff to the administration of medical facilities.
While most of the complaints that come to the public's attention are usually related to childbirth, Abbas said the guidelines are much more comprehensive. “Yes, we do have a problem with the clearly high rate of caesarean sections and hopefully the guidelines would help reduce the level to the acceptable average of 20 per cent,” he said.
However, he explained that the guidelines cover the whole spectrum of obstetrics and gynecology. “There are other major operations and other medical procedures that women go through, and it has to be the patients who make their decisions upon the informed advice of the doctor rather than the doctor deciding on behalf of the patient.”
The guidelines that are being worked out, he added, also include the requirement for consultations in cases of emergencies where it is the doctor, rather than the patient, who has to take the lead in the decision-making, especially in cases of life-threatening complications.
Abbas is determined that these guidelines would be applied and monitored “for the interest of both the patient and the doctor”. As for “obstetric violence”, which has been the subject of considerable complaints recently, he said that “it is simply not allowed already under the regulations” of both the Ministry of Health and the Physicians Syndicate. “We can talk about issues related to the level of information that patients get and the quality of decision-making, but obstetric violence is simply not allowed,” he said.
According to recent accounts gathered by rights groups in the past few weeks, women who delivered children, mostly in public and university hospitals, have made complaints related to obstetric violence of different kinds, ranging from insults and inadequate attention to lack of sensitivity, unsolicited medical interventions, or medical interventions by inexperienced physicians.
A recently issued paper shared by the Alternative Policies Solution (APS) reflected on recent surveys that showed that most participating women who gave birth at public hospitals felt that they were not well treated and that they were subjected to excessive labour induction and excessive vaginal examinations. Other complaints included lack of privacy, unkind verbal remarks, and decisions made by physicians without patients' consent.
According to Abbas, there is certainly room for better training on engagement and communication between doctors and patients. “But who is to decide when induction is necessary or not, and who is to decide how many vaginal examinations a patient needs? Actually, even among the best and most experienced obstetricians, the answers could vary; this is where the guidelines that the EHC is working on would help,” he said.
Ahmed Fayez, a consultant in obstetrics and gynecology at the leading maternity hospital, Al-Galaa Hospital, in Cairo, argues that some of the complaints related to obstetric violence stem from dominant social norms, “erroneous as they are”, whereby the doctor may feel he has a certain authority over the patient, or simply from lack of capacity, with doctors being understaffed and overworked in some hospitals.
“It is perfectly legitimate for a woman who is going through labour to want to have a family companion, usually the husband,” Fayez said. However, he added that, given the layout of the birth wards in the majority of large maternity hospitals, this is highly problematic because of the lack of separate birth sections, which means that the privacy of women at such a sensitive moment could be compromised by the presence of husbands or even mothers of other women.
Another example, he said, relates to doctors' decisions on whom to attend to first among a group of women who are all going through labour. “They would all be in incredible pain and their mothers and husbands would be in a perfectly legitimate state of panic, but it is only the doctor who can decide who is an emergency and who can wait; this is not something that everyone would appreciate – and again, it is perfectly legitimate,” he said.
According to Fayez, this is why some may unfairly compare the health care provided at public and private hospitals. “In reality, the issue is not about public versus private as much as it is about the number of patients who frequent public hospitals compared to those who attend private hospitals; the ratio is simply incomparable,” he said.
He argued that the application of the Comprehensive Health Insurance system would help resolve a great part of this problem, as it would allow patients to choose among public and private hospitals that would be subscribed to the CHI.
Fayez insisted that there is one thing that is firmly observed in all obstetrics and gynecology facilities, public or private: no doctor examines a patient without an accompanying nurse and family member. Overall, he added, most of the complaints that have surfaced related to bad experiences of women seeking obstetrics and gynecology services do not relate to harassment.
The most common problems, he argued, relate to the quality of medical practice.
“Anything from being abrupt with the patient to opting for an intervention in non-emergency situations without consulting thoroughly with the patient is a matter of practice, not behaviour–and there are training schemes that are being considered by the faculties of medicine to address this matter,” Fayez stated.
Short link: