Cesarean sections have jumped in Iraq in recent years _ accounting for 79 percent of births at private hospitals _ worrying health officials who say doctors are pushing women into unnecessary surgeries with potentially serious consequences in order to make more money.
The rise in C-sections is primarily due to private hospitals, where patients pay out of pocket. Private hospitals handled about 10 percent of births in 2010, officials said. But as Iraq's economy improves and more people opt for private hospitals, the rate of C-sections is expected to climb.
It's already having repercussions for women and Iraq's overburdened health care system. Doctors report longer medical stays for women who undergo cesareans, more women needing blood transfusions and suffering from infections, and babies with serious breathing problems.
Although C-sections can save lives when they are necessary, Adel Muhsen, the Health Ministry's inspector general, say doctors' greed is often behind the decision for the surgery. At private hospitals, C-sections cost two to three times as much as vaginal births.
"When I accompany my own patients to private hospitals, I see disastrous things there," said gynecologist Ulfat al-Nakkash, the general director of Alwiyah Maternity hospital in Baghdad. "The gang-like medical staff there fight each other over patients to do C-sections and get the money."
The rate of C-sections in Iraq has climbed from 18 percent in 2008 to 32 percent in 2010. That's on par with the U.S. rate of about 30 percent, but far higher than the global average of 15 percent, according to the World Health Organization.
Even public hospitals, which are virtually free to patients, have been opening private wings where a slightly better level of service is available _ for a price. Officials say women there are also encouraged to have C-sections.
Almost 26 percent of Iraqi women giving birth at public hospitals do so via C-section, according to the 2010 health report for the Iraqi Health Ministry.
It wasn't clear whether private hospitals treated more high risk pregnancies, which could account for the higher rate of C-sections. But officials said the common factor between women at private hospitals was their ability to pay.
Private hospital officials said the patients themselves are requesting the surgeries.
Nibras Mohammed, a 30-year-old government employee, delivered both of her children by C-sections at private hospitals.
It took her almost a year to recover from the first birth, and she had to take antibiotics for 40 days to treat an infection caused because the surgery to sew up her uterus was botched. When it came time to have her second child, she said she was terrified. She suspects the first C-section wasn't necessary.
"My doctor frightened me when I was full term. She told me that I had to do the surgery otherwise I would lose the baby because my (amniotic fluid) was becoming less than normal," Mohammed said.
Low amniotic fluid is a legitimate reason to have a C-section, but Mohammed suspects she did not have the condition and the doctor made it up to get her to agree to the surgery.
In a private hospital, a natural childbirth can cost between 300,000 Iraqi dinar to 400,000 Iraqi dinar ($250 to $330) while a C-section can cost between 600,000 to 1,000,000 ($510 to $850).
Other countries face their own debates about C-sections. In the U.S. a controversy surrounds elective C-sections, or those that are not medically necessary.
Some women fear a long, painful labor and the potential side effects such as severe tissue tearing or incontinence. Others have tried so hard to get pregnant, and they believe a C-section is safer for the baby. Some want to be able to control their delivery date.
Many women and doctors view C-sections as interfering the natural childbirth process.
In Iraq and elsewhere, once women have one C-section, they're more likely to have to have another, partly due to worries of a rupture of the uterus during childbirth. But it is possible for women to have a vaginal birth following a C-section, depending on her medical history and the type of cut made in the uterus.
C-sections take a longer recovery time than vaginal births. Like any major surgery, they also pose some major health problems including risk of blood clots and inflammation and infection of the uterus lining. Babies delivered via C-section can also have breathing problems.
Officials at private hospital say it is not greed that's driving the C-section boom but the patients themselves. Dr. Aseel Ahmed Salman from the al-Jarrah private hospital in Baghdad acknowledged the higher risks of C-sections but said many patients are uneducated, don't know the risks and just want the process over with.
"They cannot endure pain. They want the easy way. They are not even encouraged by their own families or mothers," to have a vaginal childbirth, she said. "The mothers of these wives, most of the time, come to us crying and requesting cesareans for their daughters because they cannot endure seeing their daughters in pain."
There seems to be little plan to try to lower the C-section rate in Iraq, in part because after eight years of war the government's attention has been on much more basic needs. Also, the decision on whether to have a C-section is perceived as an extremely personal choice. Muhsen, from the Health Ministry, said the decision is between a woman and her doctor, and the government cannot interfere.
Mohammed is not planning to have any more children out of fear she'll have to undergo another C-section.
"Unfortunately, I cannot be like my mother who had nine children, all were natural deliveries," Mohammed said.
World Health Organization: http://www.who.int
Royal College of Obstetricians and Gynecologists: http://www.rcog.org