Saudi Maternity: Good Business, Bad Medicine?
Christopher’s wife’s pregnancy and delivery in the UAE was the best birthing experience the couple ever had. Though they have been through it all before with two other children, there was always that sense of impending catastrophe that never seems to fade despite years and experience. On the day of the delivery they were ushered to a room where he was able to observe the workings of the midwife and other hospital staff as they prepared and monitored her vitals. He was able to hold her hand when their daughter was born. He even cut the umbilical cord. Except for the cashier, there was no male involvement. It was even a Christian hospital.
Although Chris and his wife felt the UAE government had somewhat of a hedonistic take on Islamic culture (or maybe it was the Emirati take on Islamic culture)—just the same, he remembered thinking how being in a Muslim country was so wonderful after living under the dirty looks; apparent disrespect and suspicion of being Muslim in the post 911 US.
This is why when they moved to Riyadh, Saudi Arabia, outside the little bumps in the road that happens in all pregnancies; Chris had no reservations about ‘D’ Day. Riyadh had a reputation of being religiously conservative and despite its third world demeanor, visibly more cosmopolitan than most places in the Emirates. He was working at a University and began to ask his co-workers about the best place to get prenatal and delivery services. He was taken aback when he got an odd response from one Muslim colleague that he not only thought was less than helpful, it seemed offensive at the time because he was married to a Saudi.
“Go back to the US,” Ahmed said grimly. A South African Muslim of Dutch descent, he was tall; lanky and generally jovial on most days. He seemed depressed, a mood he was familiar with due to the trials of teaching Saudi youth.
“Go back to the US?” Chris said repeating his advice to another co-worker later.
“How could I do that? The expense involved alone would be obscene—never mind the logistics. Besides having to quit my job, my wife and I were both orphans and we had six other children to take back with us,” He whined; which he often does when worried.
“Don’t worry about it. He was probably having a bad day,” his friend said.
He finally decided on a place near the university after trying various private hospitals near his home in Eshbilliah, off the Ring Road in Riyadh.
They went to a clinic for the prenatal treatment while waiting for his wife to be added to his medical insurance and then continued there until about a week or so before her predicted delivery date when he and his wife registered and hand delivered her records to the hospital.
She broke water early evening and they monitored her in a private room near the nurse’s stations. Within a few hours her doctor began to talk C-section.
At first Chris said no. “Okay,” the doctor said meekly. “It is up to you. We will wait until tomorrow to see if matters improve.”
He waited until just before midnight and went home to check on how his teenage son was holding up managing his younger brothers and sisters.
Confident that his wife would call if something new developed even if the hospital failed to, he got some rest and returned the next morning. He noticed that occasionally the nurse would inject something in the i.v. tubes connected to his wife’s wrist and arm. When his wife or he would ask about this injection, the nurse would answer “to flush the line sir.”
“The baby’s heart is getting weaker with every contraction and she hasn’t dropped down to the right position,” A new doctor lamented with motherly concern. “The longer you wait, the more danger the baby will be in.”
Chris looked at his wife biting her lip under the pain.
“I’m going to give permission,” He said to her. She nodded in distressful agreement.
The attendants quickly transferred her to a gurney. He gathered his wife’s things to put in the car for safe keeping.
When Chris returned, he attempted to enter the operating room but was stopped by an Asian nurse.
“Sorry sir, it is not allowed,” she said in a mechanical caddice.
“Why,” he said angrily.
“It is the rules sir.” Rather than insist, he decided to acquiesce at the door until she was out of surgery. When it was over, to his surprise, a man emerged. He suppressed his consternation and stood before him.
“Well, is she all right?”
“ I want to see the baby to call the Athan in her ear,” he said. After all, this was the most important rite at birth.
“Sorry sir. You can’t see the baby right now.”
“It is hospital procedure,” he said.
The next day he received a call from his wife. She said they wouldn’t let the baby stay with her to breast feed and they were giving the baby formula despite her request not to. They even left a bottle of it in the basset they brought her in.
She waited until he came for his visit that day, (his first since the delivery) to tell what had happened before they wheeled her into the operating room. She said just before going under when being prepped for the delivery, a man appeared at the operating table. She then realized she was completely nude. She cried out and he threw a sheet over her as if she were a piece of furniture.
Chris finally had to abruptly discharge his wife from the hospital before the end of their recommended convalescence because the maternity personnel began making harassing phone calls to her room, presumably in retaliation for ‘attempting’ to file a grievance against them.
His wife was traumatized and suffered a deep depression because of the experience. She was afraid to return for even a checkup. The hospital denies any knowledge or responsibility for what transpired and attributes the conduct of their staff to cultural ignorance. Among other things, it seemed hard for him to believe that Islamic birthing protocols weren’t known or practiced in a Riyadh hospital maternity ward in one of the most religious cities outside Mecca and Medina.
After he went back to work, Chris said he asked the colleague who he originally sought advice, the one he thought was being rude and disinterested and asked him to tell his story.
What he said made him feel his experience had been a blessing in comparison. “I had taken my wife to a government hospital. She had been diagnosed with a vaginal infection; but wasn’t prescribed any medication. As a result, a week later she went into premature labor. We went to the hospital emergency room.
They turned us away because they said there were no beds available. After trying several other hospitals, we went back to the hospital we had registered with (the one who turned us away). After pleading with them again, they said they would admit her but they needed a 50,000 riyal deposit. It was late Thursday and the banks were closed. I offered them 5,000 and promised to take care of them when the banks opened. They refused.
Finally a family friend (a national) intervened and spoke to someone. They finally took his 5,000 and admitted her.
Maternity gave her a c-section, but afterwards they left her in a sick room for 8 hours with no post-operative medication or treatment.
My premature child was placed on a ventilator and neglected. As a result of prolonged exposure in the ventilator, his eyes were damaged. The baby was hospitalized for 3 months. During this time, they gave the baby the wrong medication which caused bleeding of the ventricles. During the course of his stay he was given 40 x-rays. The hospital billed us 300,000 riyals. The insurance company’s maximum was 250,000. It was obvious that this was all about the money. When I tried to take my baby home, security beat me up in the parking lot of the hospital and took my baby from me. They weren’t going to release the baby until they got the 50,000 riyals they said I owed. I was arrested as a result of the incident.”
The child is around two now and has partial paralysis of his left side. He has trouble seeing through one eye. The boy’s father suspects he has a developmental delay because learning to walk has been difficult at two and a half.
Around the same time, another colleague of both men had also taken his wife to the same government hospital for her delivery. Because of hospital regulations, his wife could only have one family member in the room with her at a time. He and his mother in law decided to trade places in the room until she was ready for delivery.
At some point in all this, a hospital staff gave his wife a drug. She complained of weakness. The contractions stopped.
The doctor left the room and only returned when the husband started shouting for assistance for his wife. By this time, she had been in stirrups for twenty minutes. The room was chaos. One of the Filipino nurses kept shouting at his wife to push ‘like you take shit’. The doctor and a team of nurses came in and began massaging his wife’s mid-section— he thought to position the child for delivery. He backed away to give them room to work.
He then heard his wife scream. They had performed a hasty episiotomy (cutting the vaginal opening) without local anesthetic (customary with such procedures). This type of episiotomy is rarely done anywhere. The ‘J’ shape incision cut the infants head.
The husband said the staff had been delayed because another child had died while they were being delivered.
Such stories were not just limited to expats or to Riyadh as seen in a Saudi’s recollection of his own experience during his wife’s delivery at a Jeddah hospital:
“My uncle warned me before I took my wife to the hospital that they would try to cut her. He was right. When I got there, they came and said, “Oh, your wife is having problems—she and the baby are in danger.”
My uncle also told me, whatever you do, don’t consent to it. So I waited and waited while making Tasbeeha (repeating God’s name for protection). My wife was crying, my sister was crying and my mother was crying. We were all very afraid.
Finally, they sent a doctor who painstakingly massaged my wife’s abdomen until the baby was in position and delivered it normally.”
In each case above, patients said while they were undergoing treatment, they were repeatedly denied information or weren’t informed about the drugs being used or/and given truncated responses about the care they were receiving.
No one wanted to give their name because people who own hospitals and clinics usually have powerful friends that needed only a mood to get an expat deported or a Saudi without Wasta (nepotistic influence that can span national and racial identification) fired and marginalized. Saudi Arabia is one of the few places left in the Middle East the skilled and the unskilled could make something to send back to their families in the third world or a westerner could make enough tax free income to buy a house where he came from. There was ‘right’ and ‘wrong’ and then the reality of the world most workers left behind to work in Saudi Arabia.
Since the hospitals have no active independent oversight to monitor patient treatment, was it possible that unscrupulous maternity wards give women in labor a drug to inhibit or cease labor (Magnesium Sulfate, Ritodrine/ and Terbutaline or something like it), to manufacture a fake crisis as a ploy to perform a c-section for the increased insurance pay out?
With no effective oversight, how could anyone know?
Except the incident in Jeddah, all the above events happened in Riyadh; around the same time a few years ago; to westerners working at the same work place who sought treatment at different hospitals in Riyadh.
Was it a coincidence? What if it wasn’t? There are a variety of reasons hospitals push the cesarean option for their patients as Pat Lendt writes in her article Cesarean Deliveries: Are Mother and Child at Risk? : “If a cesarean is performed under the correct circumstances, it can be a life-saving procedure. For example, if the infant “stubbornly refuses to budge from a transverse presentation [it] must be delivered by cesarean” (Cohen and Estner 16). Unfortunately, cesareans are often performed when a vaginal delivery is possible. If cesareans are to ever decrease in number, the public and the medical profession need to examine the reasons why cesareans are often performed.”
Lendt cites five reasons for the increase in c section births: the threat of malpractice suits; doctors with a belief that once a woman has a c section, she is incapable of vaginal delivery, lack of training or experience with the normal child birth experience; the belief that cesarean births are safer and a bigger insurance pay out through physician labor, increase hospital stay because of surgery recovery.
“In reality some of “the physiologic costs of cesarean section to the mother . . . . are pain and depression, gas, infection, hemorrhage, adhesions, injury to adjacent structures, blood transfusion complications, aspiration pneumonia, anesthesia accidents, cardiac arrest, and death” (Cohen and Estner 29).”
“It is important not to forget that the infant is also often greatly affected by the cesarean. For example, the newborn may experience “jaundice, fewer quiet and alert periods after birth, iatrogenic respiratory distress, and neonatal acidosis due to maternal hypotension, inadvertentinfant-to-placenta transfusion and neonatal death” (Cohen and Estner 35). It is, therefore, amazing how many doctors continue to use this procedure so casually—especially when they are aware of all the complications involved.”
Though there have been several new studies that claim that there are no detrimental effects to future vaginal deliveries of women who have had numerous c-section births, there seems to be plenty of literature (like that cited above) and evidence to the contrary. The whole thing reminds one of sugar and tobacco companies financing studies that contradict critics. Even if there was some truth in these counter-claims- research studies regarding the safety of major medical procedure, why would you elect to have a more high risk operation if you didn’t need it?
In her conclusion, Lendt adds “What a shame it is that human life is being put at such high stakes because of fear, lack of knowledge, and money. The purpose of a cesarean is to save lives not to exploit human suffering.”
The Annals of Saudi Medicine which recently published a paper of a ten year review of cesarean births found that between 1997 and 2006 Saudi Arabian Cesarean rates have gone up over 80 percent. What is most alarming is that there was no data available regarding private hospitals or any specific statistics for those that are the most dependent and attentive to the ‘bottom line’ practice of medicine for profit. Quoting the report “Cesarean delivery (CD) is one of the most commonly performed surgical procedures in Saudi Arabia.” As reported by the Ministry of Health (MOH) in 2006, “there were a total of 784,145 surgical procedures in all government and private hospitals, of which 86,197 were CDs (11%).”
Saudi Arabia isn’t alone in this—cesarean deliveries have been referred to as a “global epidemic” by the World Health Organization.
After talking to hospital personnel and former patients who work or have had babies delivered at private and government hospitals, it appears the overall feeling among locals and expats alike is that hospitals in Saudi Arabia are pressuring patients to get cesarean deliveries because it generates bigger insurance payments.
Even if the Saudis aren’t rioting in the streets about this, the Ministry of Health should be somewhat alarmed about the condition of care in the Kingdom’s hospitals—particularly since statistics indicate Saudi population growth has declined nearly 30%. Does Saudi Arabia really need the hospitals to compound the problem of a diminishing indigenous population through the predatory profiteering of hospitals and clinics?
Granted, maybe the horror stories of a few maternity cases isn’t anything for the Health Ministry to break a sweat over; but one may suspect, amid all the quiet Masha-Allah’s (this is as God wills) murmured in the stoic tradition of Muslims grieving their lost and misfortunes, a call for hands regarding maternity fiascos may reveal greater numbers than anyone realizes.
As news spread among friends and acquaintances about my interest in the maternity mishaps in Saudi maternity wards, others began to step forward with their experiences. Their avalanche of stories, some of such overwhelming proportions, made me stop and take a week or so to come to grips with my own emotional reaction to what I was hearing.
Queries to hospitals involved in the events detailed in this article were met with no response.
The problem here isn’t a medical one, but a moral one.
Bedouin merchants for centuries, some Gulf Arabs see the person most renowned among them typically is the one who accumulates the most wealth. For them, hospitals are seen as businesses; not a refuge for the sick and suffering. Saudi Arabian doctors and nurses may feel obliged to follow the Hippocratic Oath, but like many medical care and pharmaceutical businesses in the west, owners may only see their duty is to heed the call of supply and demand.
Even with the reputed vigilant oversight and safeguards in western countries like the United States, it is not uncommon to hear about a hospital disregarding patient needs and safety for greater quarterly or annual returns. Imagine what would happen if these oversights and safeguards did not exist or if they did, weren’t monitored?
The purpose of this article isn’t to smear the Saudi Medical Establishment or cause public alarm and mayhem. It asks, what Lendt says should be asked in the wake of an enormous increase in C- section births in the US (and other places like Saudi Arabia)– ‘why or for what reasons are maternity wards performing these potentially risky operations; endangering parent and child with ever increasing frequency in the KSA?’ Besides the callous and lack of proper religious decorum and scruples in regard to hospital procedure that has become a defendable norm for some institutions, it also wishes to call attention to a possible answer to the questions surrounding the c-section rate in the KSA may involve profiteering from the suffering of the most vulnerable among us for a bigger payday.
I am told that some hospitals and clinics with birthing centers have good reputations in Saudi Arabia, but like the saying about rotten apples, it only takes one to spoil the barrel (the reputation of the industry). Health care providers also need to consider that people who have had bad experiences at their businesses seldom return for more of the same–nor do their friends they tell about it.
Although there aren’t very few places in the world safer to live in than the Kingdom of Saudi Arabia, how can anyone feel safe with the injury and possible death of the innocent?