Case study

Case Study 5: Caesarean Section and Religious Constraints (Muslim)

The following case study presents the care of a woman who has undergone FGM and the role of the LMC when birth is imminent. It is recommended that readers also read the traditional practices of Muslim women under the Cultural Profiles section to increase awareness of the practices and beliefs observed by Muslim women.

Hannah, a hospital midwife was attending to Leylo, a 28-year-old Somali woman who had undergone FGM type III. At 41 weeks of gestation there was no sign of an imminent birth so Hannah advised Leylo that an induction date needed to be considered in accordance with the hospital’s post term best practices. Leylo is not keen on induction, because she is not familiar with induction of labour, she is fearful, and she thinks it is contrary to Islam beliefs. She did not want to set a date and did not return for her following appointment for fear of being induced. A week later she arrived at maternity services concerned as the baby’s movements had slowed dramatically. An ultrasound scan revealed that there was not sufficient fluid surrounding the foetus and a CTG showed the baby’s heart beat was slow with occasional decelerations. It was imperative that she have a caesarean section.

Leylo had previously been warned by other Somali women in her family and community that Western hospitals favoured caesarean sections as a procedure of preference and often because Western doctors did not know how to deliver women with FGM. She was anxious about having a caesarean as it is not commonly practised in Somalia and usually only done when the mother’s life is at great risk. So she refused and said that she would wait until Allah deemed it was time. Hannah was concerned for the wellbeing of both the baby and mother and in conjunction with the obstetrician decided to contact a cultural worker who could recommend an Imam. Although Leylo’s English had been sufficient during her earlier visits, Hannah thought that they should also engage an interpreter to avoid any misunderstandings that might arise because of language challenges.

After being visited by the cultural worker and Imam, along with the interpreter, Leylo accepted the need for the caesarean section and agreed to the procedure. However, she looked very unhappy and seemed quite afraid.

Possible problems

Some Muslim women refuse again induction on religious grounds, believing that Allah gives and takes life; a pre-determined birth timeline is seen to be both foreign and unnatural. Inductions are regarded as interference with Allah’s will and are not easily accepted amongst Somali women (or their husbands).

Caesarean sections are not well considered amongst Somalis. Traditionally, most births are overseen by a birth attendant at home, and giving birth in a hospital and having a caesarean section in Somalia carries strong associations of death based on the circumstances that many women face when having to undergo the procedure. Protracted travel and delays in reaching hospitals, lack of medical equipment and personnel, deficiencies in sterile conditions, financial constraints, and the emergency situations in which women finally present for the procedure often result in tragic outcomes. In Somalia, a woman has one in 12 chances of dying in childbirth (the highest rate in the world) and so although giving birth is a time of celebration and pride, it is also faced with fear and a great sense of vulnerability.

In addition to the complications associated with caesarean sections, many women also experience a sense of personal failure at not being able to deliver their own baby, particularly within the Somali cultural mores.

Caesarean sections are believed by some Somali women to be used by Western health practitioners because they believe that practitioners do not know how to deal with an infibulated woman, or with their related peri-natal care. Therefore, women are not necessarily convinced by the medical indications for the procedure.

The fact that the number of children is limited with caesarean sections, is also of concern as is it customary for many Somali women to want to have big families.