Caesarean section in Yemen:

Profitable operations with fatal complications

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Munira Ahmed Al-Tayyar and Mohammad Omar

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13 May 2024

This investigation reveals that the incidence of caesarean sections in private hospitals in Yemen has been on the increase, and that the reason for the rise is to generate profit for doctors and hospitals and to save them time and effort. But this trends is exposing mothers to the risk of possible fatal complications, while the Ministry of Health remains in denial.

Maryam Al-Shamiri, 31, had no inkling that the birth of her baby would spell the end of her life. Since the fourth month of her pregnancy, she had been seeing a female doctor at a private hospital in the capital, Sana’a. The medical staff told her up to the ninth month that the pregnancy was progressing normally.

But as soon as she went into labour, the doctors told her she needed to be delivered by caesarean section. The resulting high blood pressure caused a blood clot on her brain. As a result, she spent some four months in a coma from which she never recovered and eventually died in January 2023.

Maryam’s family filed a complaint with the Supreme Medical Council, whose investigation concluded that a “technical failing” was to blame, because the person who administered the anaesthetic had been unqualified, something for which both the hospital administration and the anaesthesia technician bore responsibility. The report also pointed to "the faulty procedure of transferring the patient from operating theatre to intensive care, before her condition had been stabilized."

The decision of the Medical Council in the case of Maryam al-Shamiri

The decision of the Medical Council in the case of Maryam al-Shamiri

For decision translation please Click Here.

Maryam’s case prompted research into maternal mortality rates following caesarean sections. Data from the World Bank showed that the total number of deaths following childbirth in Yemen between 2010, and 2020, (the latest available statistics) were 1,832. According to doctors and nurses who spoke to the two authors of this investigation, caesarean sections accounts for 70 percent of all maternal deaths following childbirth.

Data from the United Nations Children's Fund (UNICEF) indicate that 317,000 caesarean deliveries were registered in Yemen between 2020-2023, out of a total number of 2.7 million births, in both private and government hospitals.

A questionnaire, which was carried out with 45 Yemeni women as part of this investigation, confirms an increase in caesarean sections deliveries. The results showed that 85 percent of the sample had given birth through caesarean section and that 72 percent of them had been operated on in private hospitals.

Births in Yemen between 2020-2023

*UNICEF attributes the major difference in figures for births between 2022 and 2023 to improved data collection in Yemen

Source: UNICEF

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Profitable operations

The Medical and Health Professions Syndicate in Hadhramaut Governorate explains that the main reason for the increase in caesareans birth, is that doctors in private hospitals receive a percentage of the cost of performing these operations. Obstetricians can charge up to 60 percent of the total cost of the operation in some hospitals, according to Dr L.A., who works in a hospital in Sana’a.

"Ninety percent of pregnant women who are admitted to hospital have caesareans, even if the patient is about to give birth. The woman comes to the hospital already in labour and is quickly referred for caesarean,” she says.

The cost of a caesarean section in private hospitals in Yemen is between 250,000 and one million Yemeni riyals ($500-2000) in private hospitals. In public hospitals the cost is no more than 70,000 Yemeni riyals ($120).

In addition to the financial return, the time factor also makes caesarean the easiest option for obstetricians and gynaecologists, according to consultant general surgeon Essam Al-Qarouda, a member of the Yemeni Society of Surgeons.

Al-Qardou quotes one gynaecologist saying: “I’m not going to sit and wait with a pregnant woman for four or five hours. I’d rather send her for a caesarean in half an hour, get home and take my cut of the cost of the operation.”

Many nurses and doctors have themselves seen obstetricians and gynaecologists trying to talk pregnant women into having caesareans. Among them is Murad Ibrahim, who works as a nurse in a private hospital in Hodeidah. He says many women have undergone caesarean sections without any medical justification, but just to benefit the hospital and because the doctors want a percentage of the cost of the operation.

The financial burden on mothers is not limited to the caesarean operation itself, but also includes incubators, which cost between 25 and 30 thousand Yemeni riyals ($60) per night in private hospitals, and 5,000 riyals ($9) in government ones.

Noha Al-Ariqi, an obstetrician and gynaecologist in a clinic in Sana’a, says: “Hospitals take advantage of the fact that the mother and the family don’t know why their newborns are put in incubators. This happens even if the babies don’t need it. And the parents agree, because they are frightened that otherwise something bad may happen.”

She thinks the whole question has become a purely money-making exercise. “Not all children born by caesarean need an incubator, and the costs are added onto those of the operation and drugs.”

Al-Ariqi adds: “The anxiety that pregnant women have over giving birth serves the interest of doctors and hospitals. Instead of the doctor sometimes waiting eight hours for the woman to give birth naturally, she decides within an hour to send her for caesarean, for which the doctors gets a 60 percent commission from the hospital.”

Al-Ariqi says that pregnant women are not told of the risks and complications of anaesthesia or of having a caesarean.

Caesareans are on the increase as a result of “indirect” pressure exerted by hospital management on obstetricians and gynaecologists to carry out more such operations, so as to achieve higher profits in a shorter time, compared to natural births. This is something confirmed by Safiya Al-Hamidi, a consultant gynaecologist and obstetrician at Al-Sabeen Maternity and Childhood Hospital in Sana’a.


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What does the health ministry say?

We contacted the Yemeni Ministry of Health and Population (in areas under the control of the Supreme Political Council) to ask about why there has been such a remarkable increase in caesarean sections. In reply, Zainab Al-Badawi, the official responsible for reproductive health official, said: “These statistics are wrong. I do not know where the Midwives Association got them from. The ministry has not closed down any hospitals over violations. But we have issued warnings and sent out standards and controls.” Al-Badawi said that committees had been set up in every government and private facility to decide on whether a caesarean section should be performed.

This answer stands in contrast to the fact that the ministry held a consultative meeting in Sana’a in March 2023, aimed at cutting the number of caesarean sections performed in public and private hospitals, and to put in place the necessary controls. Minister of Health and Population Taha Ahmed Al-Mutawakel warned at that time about the increase in unjustified caesarean sections, carried out without medical need.

In May 2022, the Yemeni parliament (which comes under the government’s Supreme Political Council in Sana’a) convened a session to discuss standardizing charges for surgical operations, and holding accountable hospitals that carry out caesarean sections needlessly.

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Intimidation and haste

One obstetrician and gynaecologist in a private hospitals in Amran Governorate told Umm Haitham (not her real name), who was showing signs of labour, that she need an emergency caesarean, because “the umbilical cord is twisted around the neck of the foetus, and there is only a little fluid surrounding it.” The doctor warned that the foetus could be lost if the operation was not carried out. Umm Haitham decided, however, to go with her husband to another doctor, to give birth naturally.

Twenty-two percent of the women who filled out the questionnaire said they had been intimidated by being told they needed a rapid caesarean. And 89 percent of this random sample, said that they had not been told that they or their newborns might be at risk if they underwent a caesarean section.

The effect of such intimidation is compounded by a widespread “misinformed cultural belief” among some women, that a caesarean section is better than a natural birth in preserving the natural proportions of the vagina. This is another reason behind the plethora of caesarean operations, according to the head of the Oversight and Inspection Committee of the Yemeni Society of Surgeons, Fahmi Ismail.

Dr Mona Al-Amoudi, obstetrician and gynaecologist, at Al-Mukalla Maternity and Childhood Hospital, also attributes the rise in caesarean rates to the doctor’s drive to save time, as well as to the fact that some women who have had a previous caesarean are less likely to opt to give birth naturally.

Other people, however, go along with the decision of the doctor, without finding out if the reasons for performing a caesarean are sound. Mohammed Al-Masqali (a young pharmacist at Al-Thawra Hospital in Hodeidah Governorate), did not hesitate in agreeing for his wife to give birth by caesarean, after the doctor warned him of the risks that “his wife could be poisoned by foetal meconium, and if the position of the foetus was inverted, and the lack of fluid around the baby.”

"I gave in because my wife was in pain, and because I would have had to sign a form releasing the hospital of responsibility, if I wanted to discharge her. So I consented to the caesarean section. Because I work in the hospital pharmacy, I would have got my wife’s procedure done free." But once the hospital's obstetrician-gynaecologist saw his wife's notes and realised that the operation would be done without charge, she said: "We’ll try and do it naturally." And his wife gave birth naturally, says Al-Masqali.

Statistics from the National Yemen Midwives Association show that, from the beginning of 2021 until the end of August 2022, caesarean sections rates were higher in private than in government hospitals. Over this period, government hospitals performed 66,500 caesarean sections, 24.5 percent of the total number of births of 270,000.

Over the same period, the caesarean section rate in private hospitals reached 37.8 percent (43,700 operations) of the total 113,000 deliveries. Anaesthesiologist Hamdi Abu Sharkia puts this down to the fact that “female doctors in government hospitals are keen to learn.”

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Complications of caesarean section

Twenty -five-year-old Umm Alia Muhammad, from Hodeidah Governorate, found herself forced to undergo a cesarean section in one of the governorate’s private hospitals, after the doctor told her a week before delivery that “the fetus is in the reverse position,” even though she had been checked regularly, and told she could have a “natural birth” without putting her or her baby at risk.

Three days after the operation, Umm Alia developed abdominal swelling and adhesions and discharge of pus from the operation site. For four months she lived on painkillers, but her condition continued to deteriorate. Five months after giving birth she finally recovered, following treatment and medication prescribed by a doctor in Sana’a.

Umm Alia's trials and tribulations were repeated a year and a half later, when she became pregnant with her second child. She had two operations; one a caesarean section and the second to remedy the after-effects of the previous cesarean.

Umm Alia’s baby also suffered complications from the operation. He was admitted five time to the children’s clinic for fever, infections and deformities in the groin area and around his penis.

Caesarean sections carry the risk of several potential complications: bleeding from the wound, blood clotting, tissue rupture, hypertension, diabetes, pelvic inflammation, and uterine adhesions.

The head of the Midwives Association in Sana’a, Sabah Al-Dhafri, points to other possible complications, including leakage of cerebrospinal fluid, pain in the back and hands, weakness of the uterine wall, paralysis and death as a complication of the anesthesia.

The questionnaire conducted as part of this investigation showed that 24 percent of newborns suffered complications during these operations, such as wounds caused by scalpels and breathing difficulties. This was particularly the case among premature babies. These newborns require an incubator, according to Jayyab Musharrah, paediatric specialist in a hospital in Taiz.

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Fear of making a complaint

Yemeni law guarantees compensation for any victim of medical error, and compensation can be claimed if it is proved that a mother was referred fraudulently for a caesarean without medical justification, according to legal advisor Abdulrahman Alzabib. “The patient and her family have the right to demand financial compensation in the event of abnormal complications,” he says.

A medical error can be proved by submitting a complaint to the Medical Council in the capital or to the relevant health office in a governorate. They will determine whether or not there has been a medical error and, if there is, refer the case to the specialist prosecutor.

Article 304 of Civil Law No. (14) of 2002:

In the case of any unlawful act or omission, whether it was made intentionally, semi-intentionally, or by mistake, and if it causes harm to another party, the person who committed the act is obligated to compensate the third party for harm suffered. This is without prejudice to any criminal penalties liable to be incurred under applicable laws.

However, 74 percent of women (according to our questionnaire) were reluctant to make a complaint if they or their newborns had suffered complications of a caesarean section. Najlaa Al-Qobati, one of those who responded to the questionnaire, attributed this reluctance to a fear of possible problems or scandals: “I did not complain when my child was cut by the scalpel, because I was afraid of getting into problems with the hospital. Hospital owners are influential people, and we were more likely to get into even bigger problems than we were finding a solution.”

Another woman, who preferred to remain anonymous, said: “I told my husband to file a complaint when I suffered complications from the operation. But he told me: ‘You want to expose us to scandal? There is nothing wrong with you. It’s finished.’”