‘Rise in C-sections coincides with more private hospitals’

ISTANBUL- Hürriyet Daily News

The number of abortions performed should be kept to a minimum as much as possible, but they should not be banned, says Professor Atıl Yüksel, talking to Daily News in his medical office in Istanbul’s city center. DAILY NEWS photos, Emrah GÜREL

The increasing number of private hospitals during the current ruling party’s health reforms appears to have had the ironic effect of producing more Caesarean births, which have been labeled as “murder” by Prime Minister Recep Tayyip Erdoğan, according to a medical doctor.

There is a parallel between the high number of Caesarean deliveries that have been criticized by Erdoğan and the growing number of private hospitals, Dr. Atıl Yüksel said.

“Although we are not sure whether there is a cause-and-effect relationship, there is certainly parallel [growth],” Yüksel, the head of the Istanbul branch of the Turkish Society of Obstetrics and Gynecology, told the Hürriyet Daily News in a recent interview.

Is there a problem with the high number of births by Caesarean section in Turkey?
The rate of deliveries by Caesarean section was 21 percent in 2003, but it reached 48 percent in 2011. This is a very high number, and this increase has occurred very rapidly. In the U.S. for instance, the rate of Caesarean deliveries was 31.2 percent in 2010, and in Italy it was 37 percent. The often-mentioned World Health Organization statistic of a rate between 5 and 15 percent dates back to 1985. This rate is not compatible with world realities. No country has set a goal of lowering their rate of Caesarean sections to between 5 and 15 percent.

Why is the rate of Caesarean births so high in Turkey?
There are many reasons for it, but there has not been enough scientific research to show which among them are the most significant. One reason is the transformation in the health system. For instance, the number of births taking place in private hospitals in Istanbul has increased considerably. There is a correlation between the rise in the number of births taking place in private hospitals and the number of births by Caesarean section. There is a parallel, but we don’t know for certain whether there is a cause-and-effect relationship.

Then the situation is ironic: The health reform the Justice and Development Party (AKP) government is so proud of may have created an undesired outcome.
It is possible to make that argument, but as I said this has not been put forward (with proven evidence). But there probably is such a relationship. This has a lot to do with privatization. There is less of a tendency to have Caesarean sections in public hospitals. But there are also other reasons for the high rate of Caesarean deliveries. One other important reason is medical and legal pressures on doctors. Doctors prefer Caesareans for the sake of delivering the mother and family a healthy baby, because doctors have been subject to an increasing number of legal suits in recent years. Not only the number of court cases, but the rates of compensation have been increasing exponentially.

This frightens the doctors and thus they prefer Caesarean sections. Another reason for the preference for Caesarean sections is that the operation has become a much simpler procedure, as compared to 20 or 30 years ago. Currently, keeping the rate of deliveries by Caesarean section at 20 or 25 percent seems rational.

So independent of how he said it and why, the fact that the prime minister raised the topic of the rate of Caesarean sections has served a good purpose because it has triggered a debate.
That’s right. A politician or a leader responsible for the country’s administration has the right to be troubled by the 48-percent rate of births by Caesarean section and question it. But the language he used is important: He said Caesarean sections were “murder.” It should not be referred to as murder. Now that it has been pointed out that the rate of Caesareans is high, the government should devise measures to address the problem by listening to scientific circles on an interactive platform, and it should have opted for a slower pace to enact a law. Actually, I am not in favor of a law. It is unheard of in the world to regulate medical operations like Caesarean sections by law. This is not seen elsewhere in the world and it is not right. We could have come together to devise other models to decrease the rate.

Is Turkey’s new law regulating Caesarean sections a first in the word? What is your view on the law?
To the best of my knowledge, yes. I have read a lot about models to decrease the rate of births by Caesarean section, but have never come across a legal regulation.

The law says Caesarean sections can be performed if necessary. These are the words. It does not say that it will be performed in the event of necessity. When you say it may be done in the event of necessity, you can deduce that it might not be performed even in those cases. I have doubts as to how the judiciary will treat a legal case regarding a patient for whom a Caesarean section was not performed. What is an event of necessity? What I get out of the word “necessity” in this case is a very serious case, a case in which a Caesarean is definitely necessary. This will leave a very narrow window for implementation, but there are many cases which are not “cases of necessity,” but in which it makes medical sense to perform a Caesarean section. Will a doctor who proposes performing a Caesarean section be guilty of something? For example, when a baby is in a breech position, there is no obligation to perform a Caesarean section, but it is also not medically wrong to do so. If the doctor performs a Caesarean and there is a complication, what would happen to the doctor if the authorities say this was not a case of “necessity?” This law will prevent doctors from working in comfort.

What you are saying is that the new law might result in risks for the health of mothers and babies.
It is a possibility. We will see how it will be implemented.

What did you hear the first time you heard the prime minister’s statement that births by Caesarean section and abortions are “murder?”
I was very irritated and annoyed, as was the whole [Turkish] gynecological community. When it is called a murder, we become the side that is committing that “murder.” Abortion became legal [in Turkey] in 1983, and it is very irritating for doctors for a procedure they have been conducting legally since 1983 to be identified all of a sudden as “murder.”

What is the situation with abortion in Turkey in comparison to the international situation?
The rates are not at levels that should cause concern. I need to underline that abortion is not a method for family planning. I, as a doctor, have always felt uneasy ending a pregnancy when there is no medical reason to do so. I favor performing an abortion if that is what the family wants, after the family has been properly informed and the risks have been explained to them. The number of abortions performed should be kept to a minimum as much as possible. It is irritating to have to perform abortions, but it should not be banned. A ban will definitely increase the numbers of mothers’ deaths.

Looking at it medically, what should we be discussing about abortion? Is there a problem with abortion in Turkey?
Abortion is not a priority problem in Turkey. The fact that it was not possible to have an abortion before 1983 was a problem, but making it legal has alleviated an important problem in Turkey.

Abortion is a sensitive issue throughout the world. What differentiates the Turkish debate from those in the rest of the world?
Actually there has not been a lot of discussion about abortion in Turkey. There was not a lot of debate either before it became legal in 1983, or afterwards. There was a situation where everyone was happy about it.

Why isn’t there much discussion?
This is a general problem with our democratic culture.

Maybe it has to do with the fact that sexual issues remain a taboo in Turkey?
This also plays a role, but the main problem is the fact that we have not yet [adopted a] democratic culture.

* Editor's note: In response to mail from readers claiming that Prime Minister Recep Tayyip Erdoğan only described abortion as murder and not Caesarean sections, the Daily News would like to draw attention to comments made by the prime minister on May 25 at the global parliamentarians' conference on population and development in which he said: “First, I am a prime minister against Caesarian sections, and I consider this murder. Second I see abortion as murder.”
To hear the prime minister’s comments, click on the following link (audio in Turkish).