Abstract
In this article, we aim to understand the prenatal experiences of, and attitudes towards, caesarean sections (c-section) among middle-class women in Türkiye, in the context of the State’s declarations about reproductive choices in recent years. These declarations addressed the following two main viewpoints: encouragement of ‘at least three children’ per family; and restrictions on caesarean sections. The authors take these discourses as an indirect intervention on women’s bodily autonomy. Within this context, this article tries to understand women’s accounts of their own prenatal experiences in Türkiye. The findings show that respondents embrace excessive medicalisation of pregnancy for the sake of their babies, and do not perceive State encouragement as being an attempt to intervene on their birth choices. In addition, participants state that they prefer c-sections, and willingly accept this service from the private sector without considering the possibility that they may not actually need the procedure.
Introduction
In 2008, the Turkish Prime Minister stated for the first time that every married couple should have ‘at least three children’ (Hürriyet Daily News, 2013), in order for Türkiye to avoid a population crisis, and for the stagnation in population growth to be remedied (cf. Yeni Şafak, 2008). Over the next 10 years, other high ranking statesmen continued to make declarations about having ‘three children’ (Hürriyet Daily News, 2013). This became a slogan in Türkiye and underscores recent policies regarding policies on reproduction.
We perceive the above-mentioned declarations as pronatalist, because in setting a clear agenda for families to have three children, women are expected to continue their ‘traditional gender roles’ (Coşar and Yeğenoğlu, 2011: 566), and to also continue to be a part of a flexible neo-liberal labour market. In this sense, State discourse about reproduction in Türkiye primarily targets women, thought to be ‘the mothers of the nation’ (Arat, 1994: 72), to the extent that supporting the idea of larger families becomes a ‘national issue’ (Korkut and Eslen-Ziya, 2011: 10). According to Kandiyoti (1998), the structure of the patriarchal family in Türkiye assumes that men are the only authority, as they are ‘bound up in the incorporation and control of the family by the state’ (p. 278). Thus, post-2008-the approximate date of the pro-population discourse started in Türkiye (Pehlivanlı et al., 2020) fits perfectly within traditional Turkish customs. Sever and Gökçiçek assert that women’s ultimate role in Türkiye is to be caregivers and nurturers; hence, marriage and motherhood are their main paths to attaining social status (Sever and Yurdakul, 2001:969).
The State’s discourse concerning the birth of new generations defines women’s choices relating to their lives and their bodies (Sümer and Eslen-Ziya, 2017). On one hand, to encourage employed couples to have children, new amendments were enacted promoting longer maternity leave and monetary incentives for more than one child. Such incentives fulfil an already existing state agenda for population increase, which exists independent of the State’s agenda to increase the population. On the other hand, the State has encroached on the personal space of women through various attempts to ban abortion and the introduction of restrictive rules for caesarean sections (c-sections; BIA News Desk, 2015). On 26 May 2012, during the closing session of the Parliamentarians’ Conference of the United Nations Population Fund, the Turkish Prime Minister, Recep Tayyip Erdoğan vehemently opposed the practices of abortion and caesarean births in Türkiye (cf. Hürriyet Daily News, 2012). Furthermore, encouragement of larger families was promoted with mentioned anti-abortion stance and various forms of political statements concerning the reproductive choices, such as the recommendation natural birth as a birthing method or disparaging c-section although it might be a necessary solution for some situations. On 27 May 2012, Erdoğan stated that the use of c-sections to deliver babies was a step towards preventing population growth in Türkiye. He stated, ‘This country’s population growth is being stopped. We need to struggle against this situation. It is a plan to erase this nation from the world scene’ (Erdoğan, 2012, quoted by CNN Türk, 2013). 1
The Turkish government of 2015 described the family as the most significant participant in the social order. 2 In Türkiye, marriage is the first step to establishing a family, and having children is the second. Married couples often feel social pressure to have children in order to become a real family, considered to be composed of a mother, a father, and their children. This pressure is imposed by family members, other families, and friends in both overt and hidden ways. 3
Choices regarding the evaluation and management of risks regarding pregnancy should belong to women. Structural and social conditions, however, mean that the experience of birth is influenced by the unequal power relationships between women and men, as well as political and medical discourses (Priday and McAra-Couper, 2011). The central argument of this article is that, within the framework of politically based social incentives, women lack information relating to pregnancy, and react with indifference to political interventions. Within the limits of our study, we focus on two main aspects of population discourse in Türkiye: the expansion of families and the restrictions on c-sections.
Our position is that these discourses, championed by the State, trap women in an impossible dilemma. On one hand, national policy encourages larger families, so women might consider having more children in order to receive incentives from the State. On the other hand, women are also expected to feel intensive mothering 4 starting from the moment of birth. However, this expectation begins not with the birth of a child but is rather a process, which also accompanies pregnancy and birthing decisions (Shin et al., 2005). The ideal mother is, thus, a selfless woman, who abandons or sacrifices her own needs for those of the child. We argue that it is important to examine the ways in which such expectations of mothers intersect with women’s own opinions concerning birth choices. Our findings show that women in Türkiye are situated within a complex set of cultural/political discourses about pregnancy and delivery, and favour delivery methods that can increase their chances of having an ideal birth. 5 Our main questions, therefore, are as follows: In what ways are women’s experiences of pregnancy and birth affected by political and medical expectations? How do mothers define the ideal birth? What are the claimed benefits, for women and their babies, of natural versus medical births? How are such benefits constituted by mere medical knowledge, and how are they embedded in social expectations? What is the role of fathers in pregnancy-related decision-making?
The following analysis of the medicalisation of pregnancy draws on qualitative, semi-structured interviews with 20 women in Ankara and Istanbul, between 2020 and 2021. The participants in this study are educated women who are employed, married, and have access to private health care services. The interviews took place during the participants’ post-pregnancy period.
In the next section (section ‘Prenatal care and the medicalisation of pregnancy in Türkiye’), we elaborate on the details of prenatal treatments and c-sections in Türkiye in the context of the increased medicalisation of pregnancy. Section ‘Methodology’ focuses on the research design, the methods used, and the data sample. We present our findings in section ‘Results’, and, finally in section ‘Concluding discussion’, we examine the results with respect to a medicalised understanding of the women’s bodies.
Prenatal care and the medicalisation of pregnancy in Türkiye
Being pregnant and having children have different meanings in different societies. Although it can be viewed as a biological and personal experience, childbirth is also a culturally and socially important event, which is an interesting site of sociological investigation. The term medicalisation was first used in the 1970s by Zola (1972). According to Zola, medicine had become an institution in the sense of a social control mechanism. Zola asserts that the power of traditional religious and legal institutions tends to combine medicine with their own rights, which has helped establish it as an important social control mechanism (Zola, 1992).
Inhorn (2006) sees medicalisation as the ‘biomedical tendency to pathologize otherwise normal bodily processes and states’ (p. 354). As Parry (2008) claimed, ‘an expert-based biomedical paradigm dominates discussion of health and frames it in negative ways’ (p. 785). In other words, it can be said that when health becomes medicalised, it becomes subject to the authority of medical institutions and number of experts within those institutions.
We see the medicalisation of pregnancy as the inevitable or logical outcome of calculating the risks involved in carrying a child. Through medicalisation, birth has been professionalised, as the cultural meanings attached to birth are appropriated into medical events (Prosen and Krajnc, 2019; cf. Lazarus, 1994; Rúdólfsdóttir, 2000). The medicalisation of birth has also seen an increased use of medical interventions, such as foetal monitoring, birth surgeries (c-sections and episiotomies), and the use of epidurals. Parry (2008) says that ‘the driving force behind the medicalization of pregnancy is the assumption of risk connected to foetal, and sometimes maternal, health’ (p. 786). In this sense, in most countries, childbirth has been redefined within a medical discourse and has become an event that aims to minimise all possible risks.
Within this discourse, pregnancy and birth are increasingly treated like diseases. Pregnant women have become disempowered, and a normal biological event has been transformed into a pathological one. Therefore, women may feel obliged to embrace more biomedical forms of birth (cf. Davis-Floyd, 2003). Mitchell (2001) declares that as a result of the medicalisation of pregnancy, pregnant women have become ‘living foetal monitors’ (p. 97).
The Turkish welfare regime has been characterised as a corporatist social security system, which links benefits to employment status (Buğra and Candaş, 2011). The AKP, before their rise to power in 2002, made three key criticisms about the former social security system: its costs were out of control, the system was fragmented, and it made the labour market less flexible. Social security was provided through three main institutions, serving different occupational groups: the Pension Fund for Civil Servants, the Social Insurance Institution for contracted labourers, and the Social Security Organisation for the Self-Employed. Following the 2000–2001 financial crises, social security reform became an ever-more important part of the AKP’s political agenda. Following their success in the 2007 elections, the AKP integrated the three institutions into one institution, the Social Security Institution. In this sense, part of the AKP’s neo-liberal agenda was a standardisation of the right to health.
Many people are employed in the informal sector in Türkiye, have no access to social security and, therefore, struggle to afford health insurance premiums. This ultimately means they cannot access certain health services. As we will see from our study, educated women with jobs are more able to afford to health care, especially that provided by private hospitals.
Following the statements by the Turkish Prime Minister and other government officials, c-sections became more restricted in public hospitals, however, the practice was allowed to continue in private hospitals, when medical grounds were cited. For our study, we focus on women who have access to both public and private prenatal care facilities, and public and private hospitals.
In today’s Türkiye, great emphasis is put on women’s roles as mothers and wives. This is also a clear message in the AKP’s call for families to have at least three children. The perception of the woman’s body as ‘the carrier of the seed’ (Delaney, 1991: 93) makes a woman’s body vulnerable to societal control and renders her womb subject to regulation by administrative powers. Therefore, abortion, c-sections, or having at least three children are significant issues, which political parties consider necessary to regulate.
According to European Surveillance for Congenital Anomalies (Taruscio et al., 2014), prenatal procedures can be classified into the following four categories: ‘Screening for Down syndrome’, ‘Indications for prenatal cytogenetic diagnosis’, ‘Screening for Structural Anomalies by Ultrasound Screening’, and ‘Termination of Pregnancy for Foetal Anomaly’. The Ministry of Health of the Republic of Türkiye (2022) recommends one visit to a gynaecologist before week 24, another every 4 weeks, from week 24 through 36, and at least one final visit after 36 weeks.
Previous studies have shown that there is a significant correlation between socio-economic status and the content of received prenatal care. Women who are employed are 3.8 times more likely to receive prenatal services, especially from the private sector (Ciceklioglu et al., 2005). Other studies linking prenatal care and social class confirm that the likelihood of receiving laboratory services as part of prenatal care was higher for women who attended private clinics (Erbaydar, 2003).
In 2015, Türkiye had the highest rates of c-sections among countries in the – OECD (Organisation for Economic Development (OECD), 2017). According to the Kadir Has University Abortion Services Report in 2016, 38.2% of public hospital patients had c-sections, while in private hospitals the rate was 70.5% (O’Neil et al., 2016: 6–7). The study of Kadir Has University also suggests that caesarean deliveries are positively correlated with higher education. Educated women tend to delay childbearing, resulting in an increased likelihood of having a c-section (Diamond-Brown, 2019; Malacrida and Boulton, 2012). 6 Indeed, women above 35 years are more likely to have a caesarean delivery, since risk of miscarriage is higher. Moreover, a c-section is negatively correlated with birth order. In other words, while the rate of caesarean delivery for all births in Türkiye was 53.1% in 2016, the share of primary caesarean delivery in all births was 26.4% (Demirbaş et al., 2018: 4). According to medical research, there are several reasons for the increasing frequency of caesarean deliveries (Demirbaş et al., 2018: 160): an increase in first-time pregnant women opting for the procedure, multiple pregnancies as a result of invitro fertilisation (IVF) treatment, physicians giving incorrect advice or decision-making, and personal reasons.
A c-section is medically required when there is an anomaly during a pregnancy or at the moment of delivery. A c-section should, therefore, be a medical necessity, however it has been shown in the studies (Erten, 2015; Şenoğlu et al., 2021; Topçu, 2021) cited above that in some cases c-sections in Türkiye have become a matter of women’s social class or level of education. Factors such as women’s fears, class, lives, or social and cultural beliefs have also contributed to the increase in c-sections. When considering potential interventions, which might reduce unnecessary caesarean operations, the possible influence of these different factors should also be investigated. It seems that women choose to receive, or doctors choose to perform, a c-section more often when this service is provided by private clinics. Contrary to the above statements of the Prime Minister and government officials against c-sections, Türkiye still had the highest rate among OECD countries in 2019. This was mirrored in our empirical study, where the majority of women interviewed named c-sections as their preferred type of delivery. We aim to understand the possible reasons behind their preference.
Methodology
To collect women’s views about childbirth in their own words, we conducted qualitative, in-depth, semi-structured interviews. We reached participants through a snow-balling sampling technique. In total, 20 women were interviewed in Ankara and Istanbul in 2020 and 2021. All interviewees had a middle-class socio-economic status, 7 a high school diploma, and some had completed further studies. They were all married and aged between 25 and 35.
In 2012, the Turkish government legally restricted the provision of caesarean sections to cases of medical necessity (Macfarlane et al., 2016) based on the idea that the procedure impedes women from having three or more children. The majority of our participants were still able to obtain high-quality c-section after 2012, but this care was generally obtained in the private sector and came at a significant cost. Our participants consistently stated that the main reason they could obtain an c-section was because they had sufficient financial resources to do so. Given this politically charged context, we wanted to explore women’s perspectives on the availability and accessibility of reproductive health services, caesarean section in particular, in Türkiye.
We prepared a set of semi-structured questionnaires, and following two pilot studies, the semi-structured questionnaire was finalised. The interviews started with demographic questions, followed by questions about the interviewee’s experiences. The interviews took place during the participants’ post-pregnancy periods and were usually carried out in participants’ homes or at their workplaces. The interviews each took approximately 40 minutes and were conducted by us in Turkish. We translated the quotes used in this article into English. The transcriptions and fieldwork notes constitute the main data set of this study. These notes were used during the interpretation of the data and, thus, indirectly became a part of the analysis of the results. Participants’ names and the order in which they were interviewed have been anonymised.
Grounded theory (Charmaz, 2006) was our methodological approach and was implemented in an iterative process where the data were interpreted in order to define core theoretical concepts and themes. All participants in our study preferred to receive prenatal care from private hospitals and private doctors. These were intentional decisions since they believed they would otherwise have waited too long for equivalent public services. Participants were asked to recount their medical experiences during pregnancy, and whether they felt any kind of social expectations as a result of the political statements mentioned above.
We view social class as a significant individual characteristic (Skeggs, 2004). The reason for including middle-class women as a reference point in this study is based on the assumption that middle-class citizens in Türkiye have diverse political standpoints. Although there are no certain clear cut between social-class positions, we took education and income as defining measures for our categorisation of class. Çarkoğlu (2008) shows the impact of education and income level upon voting choices in Türkiye. According to his work, the likelihood of support for the AKP is higher among less educated and lower income voters (Çarkoğlu, 2008: 330). In addition, spatial boundaries also influence social-class positions: middle-class individuals are characterised by residence in urban areas, follow different consumption patterns, and have different perceptions about the cultural capital they possess (Karademir-Hazır, 2014). That is to say, political tendencies might be assumed to be rather diverse, and we might expect to find women in middle-class positions in Türkiye to be less favourable to a conservative political ideology. These diverse tendencies would then, hopefully, provide a variety of productive findings for this study.
Results
In Türkiye, access to prenatal technologies is not universal: upper- and middle-class women in Türkiye willingly and disproportionally benefit from prenatal reproduction technologies. Participants in our study reported monthly visits until their third trimester, semi-monthly ultrasounds until the second half of the third trimester, then weekly ultrasounds until birth, and screening tests every trimester. Women in Türkiye register their pregnancies with doctors and are expected to attend local clinics. Midwifery as a profession in Türkiye is rare; doctors are the first contact people for expectant mothers.
In addition, some women seek private care and testing. These tests aim to help pregnant women with the provision of expert knowledge about pregnancies and to monitor, intervene, and produce a healthy normal baby. These ideals of health and normality are repeatedly quoted in reproduction discourses. An ideal timetable for pregnancy preparation and planning is drawn up. In this respect, the pregnant body is focused upon, and the pregnant woman is cast as a protector: the focus is on the growing baby, and the mother’s role is, therefore, passive, like a vehicle carrying a passenger. As prenatal tests 8 become more routine, pregnant women accept or demand such tests, even though they may have difficulty understanding the results.
This section examines the results of our study under four subheadings. Section ‘Objectification of the pregnant body by medical technologies’ discusses the pregnancy experience within the framework of our study, as a medicalised experience, ultimately due to the will of the participants. In section ‘Experiencing the social pressures during pregnancy: Shame and fear’, we show the importance of social factors in the acceptance of prenatal tests and medical recommendations as a maternal responsibility. Women internalise this responsibility and any harm that occurs during the process is accepted to be the mother’s fault. Section ‘Fathers’ roles as decision makers’ discusses the role of fathers during a pregnancy. Finally, section ‘C-sections: Preference or encouraged decision?’ indicates that pronatalist anti-c-section discourse has little impact in the case of middle-class women who have access to private resources; a c-section is rather seen as a choice encouraged by some doctors.
Objectification of the pregnant body by medical technologies
In this study, some participants indicated that they decided to have a baby in the second year of their marriage. Some of them claimed that they experienced no family pressure to get pregnant, while others noted they had felt indirect pressure from older family members. No participant indicated that they felt influenced by the State’s declarations. All participants preferred private clinics/hospitals and private doctors, mainly because they could afford the additional costs of a medicalised pregnancy.
The women interviewed stated that they had learned much about pregnancy and associated testing procedures from conducting their own Internet research before they got pregnant. Participants read a lot about pregnancy in general, the development of the foetus, or about their own diet. They were aware of risks and what they should do during pregnancy. The defining factor for a good birth, which also carries with it implications of good motherhood, is knowledge. Knowledge in this context denotes an access to information in order to understand the birth process and prenatal tests. Our study found that pregnant women believe strongly in the efficacy and importance of prenatal tests. In this sense, reproductive technologies concerning prenatal testing are welcomed by women, who want to benefit from ‘the developments of medical technologies’ (Elçin, 36 years old).
For the majority of our informants, the most salient aspect of prenatal testing was that it provides information about the pregnancy and the foetus. As discussed in the previous sections, medicalised birth discourse maintains that to have a healthy baby, such tests are necessary and, indeed, crucial. Such attitudes to testing are related to attitudes towards parenting, sickness, and social responsibility. The medicalised discourse influences women’s notions of childbirth and motherhood. Our informants saw routine prenatal testing as an advantageous and responsible action, which provided reassuring and useful information. They also indicated that prenatal testing significantly improves their chances of having a healthy baby.
In a way, these tests, paid for by the patient in private clinics, have become a routine. Women do not question whether the tests are necessary or not. They expressed that they felt confident about becoming mothers – a confidence they gained in part through the information provided throughout their pregnancy by the medical process.
On the basis of our interviews, we suggest that the routinisation of prenatal tests and diagnoses can be understood as treating the pregnant body as a vessel, which is regulated and disciplined through medical knowledge and management. Medical monitoring of the pregnant body became the norm for the participants in this study. For example, Ebru (30 years old) said, ‘Even before going to the doctor, I started to read everything on the internet. I volunteered for every prenatal test the doctor asked for. I wanted to believe in his expertise’.
Moreover, the routinisation of prenatal technology can affect women’s reproductive autonomy, often turning women into ‘objects of medical care rather than subjects with agency and rational decision-making powers’ (Ettorre, 2002: 20). For example, Elçin stated, ‘I did everything that my doctor asked for. He told me that Trisomy 21, Beta HCG, PAPP-A, and triple tests are important. He told me that these tests are the best way to understand if the baby is healthy’.
In their responses to questions about routine prenatal tests, informants were most likely to say that they provided information about their babies. They believed this information would be helpful. Thus, Ebru (32 years old) said, ‘Anything I can know about my baby is helpful’. Elif (29 years old) agreed that ‘those kinds of tests provide me with the advantage of knowing more about my baby’. In fact, a frequent sentiment was that ‘the more information I have about my baby the better’ (Ayça, 37 years old).
These findings show that the main thoughts of the participants focused on taking good care of themselves during a pregnancy, as that is the best way to ensure one has a healthy baby. The women demonstrated a deliberate and conscious choice to seek a medically assisted birth, that is, medicalisation of their pregnancy and childbirth.
Experiencing the social pressures during pregnancy: Shame and fear
The routinisation of prenatal technologies has specific consequences for women’s healthcare and their experiences of pregnancy. Reproductive technology can be either liberating or socially controlling, depending on an individual woman’s life experiences and context. As part of routine medical surveillance during pregnancy, women’s bodies ‘fade into the background’, while the foetus emerges ‘centre stage’. For the sake of a healthy baby, women’s experiences are controlled, both medically and socially.
Half of the participants described two main feelings when they did not have or skipped prenatal tests: shame (and/or regret) and fear: I knew that my mother did not have any of these tests. Yet, I also knew that I would regret it if I did not have them done. The only test I did not have was for diabetes, because my doctor said I did not need it. No interventions took place without my consent. As long as my doctor said a test was necessary, I willingly had that test because I trusted my doctor. (Ayça, 37 years old)
Throughout the interviews, participants consistently noted that mothers in previous generations did not have any of the aforementioned tests, yet they had healthy babies. Some participants were thankful that new technologies enable a mother to know so much about her unborn baby. However, as Ayça mentions, women also willingly accept whatever the doctor recommends, praising this guidance as the only medical route. Woliver (2002) noted, ‘Shifting control from the pregnant woman to doctors and other medical professionals brings with it increased power of “experts” at the expense of women’ (p. 30). In other words, in the case of pregnant women, biomedical and technological knowledge is privileged, allowing doctors to play a significant role as the medical authority over women’s experiences of pregnancy.
Obviously, all mothers want the reassurance that nothing will go wrong during their pregnancy in order to provide the utmost protection for their unborn child. What is imperative is that a woman understands her options concerning prenatal testing and the risks and benefits associated with them.
Another respondent told us that she felt confused about not being tested enough: In my 11th to 14th weeks I had the Trisomy 21, Beta HCG, and PAPP-A tests, and the doctor said that my results were just fine, so I did not need to have a triple test in the coming weeks. I was happy with the results, but I also felt the result was incomplete. I wanted to have the triple test anyway just to make sure. (Zeynep, 32 years old)
This response shows that pregnant women think prenatal care is necessary because it allows women to know certain details about their babies’ health. Many respondents thought that prenatal care is important because it ensures a better pregnancy. Zeynep’s experience, however, also indicates that women feel compelled to be informed about test results, otherwise they feel insecure about their babies’ health. Therefore, prenatal tests are considered necessary because some participants think that otherwise the baby was going to be sick. Thus, they believed that they were mentally and physically bounded to the medical knowledge about the state of their pregnancy.
Prenatal tests and the subsequent medical recommendations are socially accepted as a maternal responsibility; if women do not follow the doctor’s recommendations, any resulting harm would be regarded as the woman’s fault. Women internalise the feeling that ‘it’s up to you and it’s your responsibility to take care of your baby to be a good mother’ (Zeynep, 32 years old). Thus, in our participants’ experiences, compliance with medical recommendations and the use of all available technologies to ensure an optimum pregnancy emerge as part of the norm of ‘being a good mother’ (Zeynep, 32 years old). However, what one can learn as a mother depends on one’s ability to access the latest prenatal testing technology.
Fathers’ roles as decision makers
As part of our interest in women’s experiences during pregnancy we asked them whether their husbands’ presence during this time was a comforting one. Informants indicated that they received support in decision-making, especially for tests such as amniocentesis, which carry considerable risks for both mother and baby. They also stated that the main idea that influenced their decision on whether to undergo a c-section was in order to have a healthy baby. They expressed that they felt pressure to be good mothers, which they equated with being able to have a healthy baby.
The results of the study also suggested that fathers have the power to decide whether or not a certain prenatal test is performed. Gendered roles and institutions shape individual decisions, how they are made, and which strategies are pursued (Korkut and Eslen-Ziya, 2011). Thus, even couples who attempt to share decision-making on taking tests like amniocentesis, find themselves affected by the reality of a male dominance in decision-making.
However, three participants emphasised that their husbands’ absence during consultations had an adverse effect on their feelings. These participants justified the absence by saying that their husbands had to work. We read this situation as a sort of gendered division of labour with regard to reproduction. Women are considered to be the ultimate caregivers and nurturers, and, therefore, a father can be excused if he has to work, as anything related to childbirth is ultimately attributed to the woman. Yet, as mentioned earlier, fathers might still have the last word in certain decisions.
C-sections: Preference or encouraged decision?
All respondents noted that they gave birth in private hospitals. Participants preferred c-sections over natural births, and none indicated disagreements with their doctors over their chosen birth method. 9 Some participants reported that they would have preferred a natural birth, but this was not possible because their babies were in a breech position. Another participant decided to switch to a c-section because she experienced so much pain during the birth, and another participant’s doctor was due to go on vacation and, therefore, the mother chose to have the baby beforehand.
Fulya, who delivered by c-section, mentioned that her doctor told her that she had no other option than a c-section because her baby was in the breech position: My baby did not turn until the 39th week. So, my doctor told me that the safest way was a c-section. He also said that he could turn the baby with intervention, but it would create unnecessary stress for the child.
Another respondent, Pınar, indicated that the umbilical cord was curled around her baby, so her doctor recommended a c-section. Other respondents mentioned similar explanations for not having a natural birth.
Some participants stated that it was their choice to have a c-section, although it was also encouraged by their doctors for certain medical reasons. Other doctors suggested a c-section for non-medical reasons: Esra told us that she actually wanted to deliver her baby in the natural way, but as her baby came late, her doctor wanted to perform a c-section: It was summer. Time for vacations. My doctor told me: ‘If the baby does not come before next week, and you still want me to be present at the birth, we need to perform a c-section’, because she was going to take a vacation. I was very disappointed at the time, then I got used to the idea. (Esra, 35 years old)
Esra’s experience is one example of an encouraged c-section. Even though c-sections are disapproved of in contemporary State discourse regarding reproduction, Türkiye still has one of the highest rates of c-section deliveries in the OECD because the procedure is preferred by both women and their doctors. 10 Although it often poses as much risk as a natural birth, women are rarely informed about such risks. Often, they choose to have a c-section simply because they think they will feel less pain during the birth. Doctors also encourage the procedure. They sometimes make an excuse for their recommendation, for example, telling the patient that they will be on their vacation by the time the baby is to be delivered, as in Esra’s experience above.
These examples indicate that the pronatalist, anti-a-section discourse seemingly has little impact in the case of middle-class women who have access to private resources. The neo-liberal orientation in the Turkish health sector objectifies women’s bodies as baby carrying machines, and the c-section is presented in this framing as a decision encouraged by the doctors.
Concluding discussion
The priority that recent prenatal medicine has placed on the production of a healthy baby – which means that pregnancy is subjected to medical surveillance – has become the norm in Türkiye. Compliance with medical requirements and the use of all available technologies to ensure an optimum pregnancy are emerging as the standards of ‘good motherhood’. Women in our study had the tendency to comply with this norm. They stated that they felt secure when they received information about their baby through prenatal tests.
Nevertheless, we believe that the routinisation of prenatal tests and diagnoses has effectively made the pregnant body a vessel that is increasingly constructed, regulated, and disciplined through medical knowledge and management. The women participants in this study indicated that they believe these technologies are necessary and useful procedures in preparing for motherhood. Prenatal tests and subsequent medical recommendations are perceived as maternal responsibilities; if women do not follow the recommendations, they think any resulting harm to the baby will be seen as their fault. Women internalise the feeling: It’s up to you and to be a good mother, you are responsible for your baby.
Gendered roles within the family also shape decision-making in terms of prenatal testing and procedures. Thus, even though husbands might fail to participate in monthly monitoring because they have to work, they still play a role in decision-making with regard to the taking of tests such as amniocentesis. Any discourse about reproduction that emphasises the institution of family indirectly addresses women most of all. Based on our findings, we suggest that not only the political discourse but also ‘the neoliberal structuring of the health system’ (Buğra, 2014: 150) plays a significant role in shaping a social order in which traditional gender roles are reasserted.
Finally, the majority of respondents in our study asserted that they preferred to give birth by c-section. Some mentioned that their doctors cited potential medical reasons in support of the decision, such as umbilical cord problems, physical anomalies, excessive weight of the baby, or the mother’s high-blood pressure. They did not confirm these explanations with other doctors as they did not seek a second medical opinion. Three respondents stated they would have preferred a natural birth, but in two cases, there were medical situations preventing it. In the remaining case, the woman’s doctor told her that she (the doctor) planned to take a vacation and that if the baby was born late, she would not be there to deliver it. Because she did not want to risk having a different doctor at her birth, the mother decided to have a c-section instead.
Our findings indicate that women in Türkiye are routinely encouraged to deliver their babies by c-section. We also found that the middle-class women in our study preferred to receive pregnancy treatment at private hospitals 11 and most of them preferred C-sections. Participants’ doctors did not contradict their decisions and offered medical justifications in support of the c-section procedures. No other doctors or institutions were consulted to obtain second opinions.
Technologies and discourses about reproduction have impressed certain attitudes, behaviours, and expectations upon women and men in many cultures for a long time. It is one of our arguments that the regulation of reproduction in Türkiye can be understood as a power mechanism that reinforces male dominance over the institutions of family, marriage, as well as the broad social order. At the same time, this very order depends on common sense norms about appropriate birthing customs, and what defines appropriate or normal is determined by the society and the reproductive technologies it has at its disposal. It would not be a simplification to argue that women are objectified by these technological discourses. In fact, they are only effective vessels of the key subject, the foetus, which is a subtle subject of the reproductive technologies. The priority placed on the production of healthy babies means that pregnancies are subject to medical surveillance, a set of circumstances that has institutionalised c-sections as the norm in Türkiye.
The closing reflection in this study raises an important question about the relationship between the use of prenatal tests and the potential absence of meaningful human connections in prenatal care. We suggest that women’s reliance on these tests for reassurance might, in part, be a response to the perceived lack of emotional support within the healthcare system. This perspective underscores a critical dimension of modern healthcare that warrants careful consideration.
It is crucial to recognise the pivotal role that prenatal tests play in monitoring the health of both the mother and the foetus. These tests offer valuable insights, enabling early detection and intervention in case of potential issues, ultimately ensuring the well-being of both individuals.
The emotional well-being of expectant mothers during pregnancy is of the utmost importance. Pregnancy often brings about heightened emotions, anxieties, and uncertainties, and a lack of human relationships and emotional support within the healthcare system can intensify these feelings. Consequently, it is critical to understand what alternative means of providing reassurance to pregnant women – aside from prenatal tests – are available.
One approach involves providing women with comprehensive education about pregnancy, including information about potential complications and the significance of regular prenatal care. Equipping women with knowledge can help alleviate anxiety and reduce the perceived need for extensive testing.
Another avenue is the provision of continuous emotional support. This support can be delivered through various channels such as midwives, doulas, or support groups. These resources offer a consistent source of comfort and care throughout the pregnancy journey.
Involving women in shared decision-making regarding their prenatal care is another strategy. When women have an active role in decisions, including the choice of tests, they gain a sense of agency and control over their healthcare decisions.
In addition, a holistic approach to care that takes into account the physical, emotional, and psychological well-being of pregnant women can reduce the inclination to rely solely on tests for emotional reassurance.
Finally, enhancing doctor–patient communication is crucial. Ensuring that healthcare providers establish open and compassionate lines of communication can go a long way towards addressing emotional needs and concerns during pregnancy.
In conclusion, while prenatal tests are indispensable tools in modern obstetric care, the inquiry into the emotional aspects of prenatal care and the need for human relationships is valid. Striking a balance between medical monitoring and emotional support is essential for empowering pregnant women and ensuring a positive pregnancy experience. The Turkish healthcare system should continue to evolve to meet not only the medical but also the emotional needs of expectant mothers, thus offering a more comprehensive and supportive approach to prenatal care.
Footnotes
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research, authorship, and/or publication of this article.
Ethical Statement
Informed consent was obtained from all individuals included in this study. The research related to human use has been complied with all the relevant national regulations, institutional policies and has been approved by the authors’ institutional review board or equivalent committee.
