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Refugees and Other Displaced Women Face Higher Rates of C-section

Key findings

  • Among asylum seekers and refugees, cesarean sections may be performed for expediency in places where health care resources are strained
  • Rationales against cesarean section include the risk of physical and emotional complications as well as logistical issues such as distance from follow-up care, threat of relocation and increased exposure to pathogens
  • When a cesarean section is unavoidable, physicians should take pains to obtain informed consent by consulting a professional interpreter or a patient advocate

According to the United Nations, the world's population of refugees and asylum seekers is at a record high. In 2017, an estimated 16.2 million people were newly displaced, for a total of 68.5 million people who have been forcibly displaced as a result of persecution, conflict or generalized violence.

Female refugees are often obliged to enter health care systems where the stresses of this crisis may lead to expedient obstetrical solutions, including cesarean sections. A recent article in the Open Journal of Obstetrics and Gynecology by Helai Hesham, MD, a female pelvic medicine and reconstructive surgery fellow at Massachusetts General Hospital, and Annekathryn Goodman, MD, a gynecologic oncologist and co-director Mass General Global OB/GYN, reviews what is known about the obstetrical experiences of displaced women.

Who's Affected?

The reviewers start by defining the terms used by the United Nations:

  • Asylum seekers and refugees are forced to leave their homes to escape war, persecution or, less often, natural disaster. They may seek protection in another country or be internally displaced within their own country. In either case, they may live in camps or among the host community
  • In formal terminology, refugees are asylum seekers who have had their asylum applications accepted
  • Migrants leave their country for economic reasons to seek a better life. Due to problems such as poor health and inability to speak the language of their host community, they often encounter some of the same problems with health care systems that asylum seekers and refugees do

Overreliance on Cesarean Section

Communities that host displaced people may face the challenge of delivering obstetrical care without a sufficient number of trained providers available for labor management and safe deliveries. Paradoxically, this can lead to a greater number of cesarean sections.

The rates of cesarean section in refugee and migrant populations are unknown but are thought to be higher than national averages. As an example, the reviewers cite the case of Greece, which is bearing the brunt of the influx of refugees into Europe. Between 1994–2000, the rate of cesarean sections there was about 30%; in 2013, it was 45% in public hospitals and 65% in private clinics.

Reasons to Avoid Cesarean Sections

Even under the best of circumstances, cesarean section is associated with risk of hemorrhage, endometritis, wound complications, injury to pelvic organs and thromboembolic disorders. In the U.S., it's estimated that 8% of cesarean deliveries have at least one complication, and maternal death is a possibility, although the incidence is very low.

Women who undergo cesarean delivery often experience strong feelings of loss, anger and failure. Those emotions can be magnified by the stresses of living in a refugee community. Moreover, language barriers may leave the woman feeling she didn't consent and perhaps does not even know why the surgery was done.

Cesarean section is also problematic among displaced women for logistical reasons:

  • Many patients live far from medical facilities and are unable to return for follow-up care
  • Asylum seekers, refugees and migrants are prone to relocation without notice, and sometimes deportation. Travel is difficult during any type of postpartum care, but a postoperative patient is at particular risk of complications, including thromboembolism if there are long periods of immobility
  • Displaced women in some living situations are at increased risk of environmental exposure to pathogens, leaving them vulnerable to surgical site infections

Recommendations

The reviewers make several recommendations to clinics that care for displaced populations:

  • Ease any shortage of physicians by using midwives and other midlevel providers to assist with antenatal care and vaginal deliveries
  • Train traditional birth attendants
  • Ensure informed consent for cesarean deliveries:
    • If a language barrier exists, enlist the help of a professional interpreter via telephone or video if not available in person
    • If the hospital lacks interpreters, try to arrange with someone from the woman's community to help with interpretation and serve as her advocate
    • Have consent forms for various situations translated into relevant languages and keep a supply of them on hand

68.5
million people who have been forcibly displaced as a result of persecution, conflict or generalized violence

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