A government campaign to encourage women to give birth via vaginal delivery has drawn criticism on the grounds that it stigmatises mothers who choose caesareans.
In October 2024, Turkey’s Ministry of Health launched a “Normal Birth Action Plan” to encourage women to give birth via vaginal delivery. The campaign, announced in a public service ad titled “Mum, we did it”, prompted a backlash on social media. The Turkish Psychiatric Association also criticised the public service ad for being unscientific and portraying vaginal births as a “success”, making women who have caesareans feel guilty and inadequate.
Turkey leads the world in caesarean birth rates. According to the Ministry of Health, 60.1% of live births in 2022 were performed via caesarean section. Data from the Organisation for Economic Co-operation and Development (OECD) recorded Turkey’s caesarean rate in 2021 as 584.2 per 1,000 births. International health authorities recommend caesarean deliveries only when the health of the mother or baby is at risk.
Launched in October 2024, the action plan was announced with the participation of Emine Erdoğan, the wife of President Recep Tayyip Erdoğan. It includes measures such as establishing prenatal schools, expanding mother-friendly hospital standards, increasing the authority of midwives, assigning a midwife to every pregnant woman, and monitoring caesarean deliveries.
But the announcement – and the ensuing debate – has shone a light on deeper problems in Turkey’s health system. Associate Professor of Obstetrics and Gynecology Dr. Murat Ekmez argues that the high caesarean rates cannot be explained solely by women’s choices.
“The management of births should involve both midwives and specialists under physician supervision. However, there are not enough midwives. Moreover, hospitals lack the necessary facilities to ensure a comfortable vaginal birth for women,” he says.
Setenay, who had a caesarean four years ago, describes her experience: “Labour was induced due to my baby passing meconium and a decrease in amniotic fluid. However, due to the midwife’s aggressive behavior, I opted for a caesarean. Since general anesthesia wasn’t applied, I was able to bond with and breastfeed my son immediately.”
Expressing her feelings after watching the ad, she says: “Labeling vaginal birth as ‘normal’ is deeply problematic. Manipulating the mother-child bond to make women who have caesareans feel inadequate doesn’t encourage vaginal births.”
Turkey has approximately 60,000 midwives, and the Ministry of Health aims to increase this number. Dr. Ekmez is optimistic about this initiative and stresses that childbirth is a 24-hour healthcare service. However, in regions where childbirth practices are less frequent, teams cannot function effectively, pushing doctors away from vaginal births and leading to higher caesarean rates.
Dr. Hatıra Topaklı, an executive member of the Turkish Medical Association’s Women’s Health Committee, considers the issue a systemic healthcare problem. In family health centres with insufficient midwives and nurses, midwives are often overwhelmed with outpatient services, leaving them unable to adequately monitor and support pregnant women. This leads many women to opt for caesareans, which seem less uncertain.
Caesarean delivery is a surgical procedure carrying risks such as infection, bleeding, and complications from anesthesia. Additionally, a first caesarean delivery often necessitates caesarean sections for subsequent births, increasing the likelihood of complications like uterine rupture.
Professor Dr. Ayşe Akın, Director of the Research and Application centre for Child Health and Family Planning at Başkent University, considers Turkey’s caesarean rates unacceptable. “Unnecessary caesareans in first births have contributed to this rate,” she says. “There is no rule that vaginal birth is impossible after a caesarean. However, we physicians are generally reluctant to take even minimal risks for the mother and baby in such cases.
“This foundation should not have been laid in the first place, and the public was misled. Caesarean births were portrayed as a way to avoid severe labour pains, while the side effects and complications of surgery were downplayed.”
Dr. Akın emphasises that access to healthcare is a fundamental right, just like the right to life:
“The state is obligated to ensure that its citizens can fully exercise this right. Instead of interfering with fertility, governments should ensure that families, individuals, and especially women can fully exercise their rights, including autonomy in decision-making and freedom from violence, which are often violated.”
Dr. Akın stresses that caesarean birth rates should not be turned into a political issue, adding that non-scientific discourse creates confusion. She also calls for the removal of the public service ad – in which a foetus is shown speaking – as it places psychological pressure on mothers.
Professor Dr. İsmail Mete İtil, President of the Turkish Society of Gynecology and Obstetrics, explains that caesarean rates are considered a general health indicator, and the government aims to reduce them.
“Another reason is Turkey’s ageing population,” he adds. “At least three births are recommended to counterbalance this trend. However, for various reasons, this number is not achieved. One reason is caesarean births. Patients are often unwilling to undergo multiple caesareans.”
Globally, caesarean rates have risen from 7% in 1990 to 21% in 2021. The World Health Organization (WHO), which recommends a caesarean rate of around 15%, predicts that it will rise to 29% – nearly one third – of all births by 2030.
While the reasons vary by country, factors such as the decline in skills for difficult vaginal deliveries, the convenience of scheduling birth dates, and the perception of caesareans as more profitable stand out.
Professor İtil disagrees with the notion that caesareans are more profitable for hospitals. He notes that high rates are not unique to Turkey but are also common in countries like Mexico and Brazil.
The law has also contributed to rising caesarean rates, adds professor İtil, pointing out that obstetrics is one of the most frequently litigated medical fields. Due to the dual responsibility of caring for both the mother and baby, physicians often opt for caesareans as the least risky method to avoid malpractice suits or even prosecution.
“Both types of delivery carry inherent risks,” says professor İtil. “Sometimes the process doesn’t go as the patient expects, and the physician chooses the least risky method for the mother and baby. Nevertheless, they may still face legal issues.”
An increase in violence against healthcare workers has also led doctors to adopt defensive practices. In 2023, violent incidents by 86% compared to the previous year, reaching 457 incidents. Dr. Ekmez explains that trust between doctors and patients has eroded, especially under the governing Justice and Development Party (AKP), largely due to the commercialisation of the healthcare system.
“Even when caesareans are medically necessary, patients have come to believe that doctors perform them for financial gain. As a result, many private hospitals have had to equalize the costs of vaginal and caesarean deliveries.”
Ece, who gave birth to her daughter through vaginal delivery five years ago, says she felt deep sadness upon watching the public service announcement: “The fact that the bond between a mother and her baby is reduced solely to vaginal delivery deeply upset me. I felt the pain of mothers who gave birth via caesarean. I cannot see any goodwill in this video.”
Emphasising that the bond between a mother and baby is not dependent on any condition, Ece shared the challenges she faced during her vaginal delivery. “I chose to have a vaginal delivery of my own will. However, I had no contact with a midwife until the moment of delivery. Despite repeatedly asking, I was told that the midwife would only be present during the delivery.
“At a time when I needed privacy and trust the most, three different midwives, whose names I didn’t even know, examined me. It’s impossible to access midwives until the moment of delivery in Turkey’s healthcare system. Moreover, I gave birth in a private hospital, paying a significant fee. Although healthcare is a right, I had to purchase it, and even then, I wasn’t accompanied by a midwife during my pregnancy. Under these circumstances, the high rate of caesarean births is not the choice of women but the result of a commercialised system.”
In Istanbul, inquiries with private hospitals revealed that vaginal delivery costs range from 50,000 to 230,000 Turkish liras, while caesarean costs range from 70,000 to 260,000 Turkish liras. The wide variation in prices is attributed to differences in insurance coverage.
In neighbouring Tekirdağ, caesarean delivery costs an average of 20,000 Turkish liras at private hospitals. State hospitals, when contacted, provided mixed responses, with some stating that both types of delivery are free, while others indicated the decision depends on the patient’s condition and the attending physician.
Some critics see the vaginal birth campaign as an extension of AKP government policies that seek to regulate women’s bodies – chief among them, a de facto ban on abortion that means the procedure is largely unavailable in public hospitals, despite being allowed under Turkish law.
Dr. Topaklı points out that the state no longer provides free contraceptive methods, increasing the risk of unplanned pregnancies for women. “This public service announcement sends the message that women cannot decide, along with their doctors, how they will give birth,” she says.
“Being a woman is reduced to fertility alone. Our expectation from the government is to focus on policies for the health and education of already-born children instead of interfering with how many children women should have and how they should give birth.”
Health professionals interviewed by Inside Turkey argue that promoting vaginal delivery must be scientific and non-discriminatory. Suggestions include expanding education on childbirth and reproductive health, increasing the number of midwives, making painless delivery methods more accessible, improving hospital conditions and protecting doctors from violence.
The Ministry of Health did not respond to a request for comment.