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Caesarian deliveries: Between stigma and 'trend'

More and more women are giving birth by cesarian section amid the general stigma around the delivery method as not "normal". Reducing the stigma and the rate of cesarean births must go hand in hand to promote both maternal and infant health in Indonesia.

Amahl S. Azwar (The Jakarta Post)
Bali
Wed, May 5, 2021

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Caesarian deliveries: Between stigma and 'trend' Clemency Charissa believes that the method a woman chooses to give birth is her decision and only hers, and not for others to judge. (JP/Courtesy of Clemency Charissa)

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n her six years as an obstetrician-gynecologist (OB-GYN), Dr. Ivanna Theresa Setijanto has seen many women under her care being shamed, often by their loved ones, for giving birth by cesarean delivery, or C-section.

Ivanna, who practices at St. Carolus Hospital and Angsamerah Clinic in Jakarta, recalled an experience she had in 2017, when a patient was berated by her mother-in-law while she was recovering from the surgical procedure.

“I told her [the mother-in-law], ‘Ma’am, there is no need to make a fuss about this. You’ve already been given a grandchild,’” the 36-year-old doctor recounted. “As doctors, we need to make an extra effort to explain to family members when C-sections are needed.”

Ivanna said her patients often felt intimidated when their mothers and mothers-in-law told them that they’d never had a C-section. In one instance, a patient’s mother boasted that she had had seven children, all natural births. In another, a woman insisted that her daughter-in-law should not have a C-section, even after the patient’s cervix had dilated to 8 centimeters but the baby’s head was still not visible.

This is called crowning, indicating that the baby has entered the birth canal and labor is progressing.

“As a doctor, I have one goal and only one: the safety of the mother and her baby,” said Ivanna.

“Every birth has its own [difficulties]… So why should we debate over [which method is best]?" she added.

Ivanna stressed that “vaginal birth” was the medical term for births that did not involve a C-section.

"The main problem is [that] our society labels vaginal births as ‘normal’,” she said, while admitting that she sometimes used the vernacular term in referring to vaginal births when speaking to her patients.

“We have to use words that are easy to understand,” she explained.

Ivanna Theresa Setijanto, an obstetrician-gynecologist, says that her goal is to ensure the safety of both the mother and the baby, and that a cesarean delivery is sometimes necessary to achieve this.
Ivanna Theresa Setijanto, an obstetrician-gynecologist, says that her goal is to ensure the safety of both the mother and the baby, and that a cesarean delivery is sometimes necessary to achieve this. (JP/Courtesy of Dr. Ivanna Theresa Setijanto)

When a patient’s family member like a husband or mother-in-law wanted more information about what a cesarean delivery entailed, Ivanna always encouraged her patient to bring them along to an appointment.

“If necessary, she can bring as many [relatives] as she likes, although perhaps that would be difficult now because of the pandemic," she added.

Support vs. stigma

Clemency Charissa has a 3-year-old daughter and is expecting her second child in June. She said that a C-section did not occur to her when she was pregnant with her daughter.

“I was confident when I said that I was brave, and I really wanted to give birth normally,” said the 32-year-old Jakartan.

One December morning in 2017, Clemency started having contractions and was rushed to the hospital. She experienced painful contractions for hours, but the doctor said she was only in the second stage of labor. When her water finally broke, the fluid had a greenish tinge.

The doctor then suggested that her baby was under a lot of stress, that the fluid could be “poisonous”, and recommended a cesarean. Clemency and her husband both agreed.

Clemency still had to wait for an operating room to become available while her pain became more unbearable. She wondered whether the pain she was experiencing was the same for all women who gave natural births.

“All I know [is that] the operation saved my life and my baby’s life,” she said.

Her family members asked her about the C-section, but once she explained what had happened, they all supported her decision. Clemency’s mother was particularly supportive of her daughter, as she had developed postpartum complications with Clemency’s older sister and so had given birth to Clemency by C-section.

Clemency became aware of the social stigma around cesarian births when a friend and mother of two told her that she would not be satisfied until she gave birth naturally. Later, Clemency’s sister told her a teacher suggested that “a woman would not be complete” until they gave birth naturally.

“My heart pounded in anger. Especially [because] those words came from a woman. It’s really unfair to judge women for their choices,” said Clemency.

“If someone can give birth normally, she should be grateful. But that doesn’t mean she has the right to look down on other women who give birth via C-section.”

Rachelle Veronica Kandou, a 36-year-old Jakartan, gave birth to both her children by cesarean. When she had thyroid surgery in Singapore in 2006, her doctor advised her to give birth to any future children by C-section, because it would be dangerous for her to “strain her muscles”.

“I’m aware of the stigma. But I’ll always fall back on my support system. Why should I care about other people’s opinions?” Rachelle said.

Rachelle Veronica Kandou gave birth to both her children by cesarean section, as recommended by a doctor during an unrelated surgery before she became pregnant with her first child.
Rachelle Veronica Kandou gave birth to both her children by cesarean section, as recommended by a doctor during an unrelated surgery before she became pregnant with her first child. (JP/Courtesy of Rachelle Veronica Kandou)

Rissa Septiani, 33, a teacher and a resident of Cikarang in Bekasi, West Java, also gave birth to her two children by C-section. She had the procedure with her first child because the baby was in an oblique or horizontal position. With her second child, who was born on April 5, her doctor recommended a C-section because she had a thin uterine wall.

This condition can present complications during a vaginal birth, and can pose a risk to the mother’s health.

“I’m still recovering after the birth of my second child,” said Rissa, adding that her parents had been very supportive of her during the birth of both her children.

Rissa admitted that others often asked her about her C-section. One person even suggested to her during her first pregnancy that “village midwives” could “fix” her baby’s position so that a C-section would be unnecessary. Rissa simply shrugged off the comment.

“It’s painful enough thinking about my C-section scars. I won’t let the words of other people bother me,” she said.

Rissa Septiani is recovering from her second  cesarean birth, both unplanned procedures. Rather than listening to the negative comments of others, she turns to her
Rissa Septiani is recovering from her second cesarean birth, both unplanned procedures. Rather than listening to the negative comments of others, she turns to her "support team": her parents. (JP/Courtesy of Rissa Septiani)

Not a ‘trend’

According to a non-peer reviewed study led by Sage Wyatt made available as a preprint last September, the cesarean birth rate in Indonesia has increased over the last two decades, from 4.0 percent in 1998 to 18.5 percent in 2017. The study also found that the cesarean birth rate in urban areas was almost two times the figure in rural areas in 2017, respectively at 22.9 percent and 11.8 percent.

Meanwhile, data from the Health Ministry’s Basic Health Research (Riskesdas) shows that 17.6 percent of all births in 2018 was delivered by C-section, up from 15.3 percent in 2010.

Ivanna said that while the stigma around C-sections should be reduced if not eliminated, the surgical procedure should not be viewed as “a trend”, noting that young women sometimes posted their C-section experiences to social media. In urban areas, more and more Indonesian women were opting for cesarean births.

“Our goal is for C-sections to be performed in cases where [vaginal] delivery is not possible,” she stressed, and that the procedure had more risks compared to natural births.

Clemency also agrees that the stigmatization needed to end.

“Erasing the stigma will have a positive impact on [women] who have C-sections. However, future mothers should not use [the absence of C-section stigma] to look down on vaginal births. If it is possible and there are no obstacles, it’s better if a woman can give birth [naturally],” she said.

Christa Victoria, a 31-year-old Jakartan, also believes that vaginal births are still the best option, even though she has had a C-section. For her, protecting the mental health of young mothers is the priority.

“We must not let a mother have a mental breakdown because she can’t give birth [naturally] because of medical issues,” she said.

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