Rise of caesarean births spark concerns
When Abimbola Kayode was pregnant with her first child, she made a decision that shook her family. She opted for a caesarean section (CS). She had no medical condition to necessitate a CS, and her doctors didn’t even suggest it.
Her family’s reaction was predictable. “People are running away from having a baby through a CS, and you are choosing it,” her cousin Dayo said of the family’s reaction to Kayode’s decision.
Kayode was firm in her decision five years ago. “During antenatal, we saw women who chose CS just go into the theatre and, shortly, the surgeons wheel out both mother and baby,” she had said.
“But those who chose vaginal delivery are in there, screaming for four hours.”
Labour is painful, and Kayode didn’t want any part of it.
Across West Africa, an increasing number of women are siding with Kayode’s decision-and “there is little evidence to explain this trend,” four researchers wrote in a paper back in 2012 in the International Journal of Women’s Health.
They surveyed 843 women attending antenatal clinic in a primary health centre, a secondary centre and a tertiary health facility in Ibadan.
Nearly four in 10 of the women were already aware they could demand a CS, most of them women with more than secondary education. Nearly half of them got their information about CS from either a doctor or a friend.
Their reasons for demanding a CS varied, but seven in 10 of them were afraid of labour pains. The others were worried about the outcome of labour or feared they would develop faecal or urinary incontinence.
That survey only tested their awareness of CS. But the willingness to request one was still in doubt. Only six in 100 actually requested a CS. Half of those willing to request a procedure were “likely to be criticised, mainly by their husbands,” the survey found.
Skip forward to 2019, and the number of women opting for an elective CS is rising.
“I belong to a WhatsApp of new mums. Majority of them said they put to bed via CS. I also put to bed last year through CS,” said a woman on a doctors’ online platform on Thursday. Some were medically recommended, the others optional.
Seconds later, another message from a participant on the platform: “My colleague’s wife who put to bed today did elective CS.”
To understand the growing rate of elective CS, look to tertiary hospitals. That’s where the surgeons with the scalpel mostly work. Within a two-year period, 504 women at Usman Dan Fodio University Teaching Hospital underwent a CS to have their baby. Almost half of them (43%) were elective, the others were emergencies.
A quarter of the women who underwent emergency CS did so because their labour was obstructed. But nearly 40% of women who opted for an elective CS had already had a previous CS.
The pattern is similar in hospital records researchers have poured through in tertiary hospitals in different regions of Nigeria.
“The sensitivity, the awareness is increasing,” says Dr Ugochukwu Arinze. “But the attitude is still yet to increase. People are yet to embrace elective CS as a mode of delivery in our present-day Nigeria.”
Cost is a factor. Michael Nwabueze paid around N110,000 for his wife to undergo a CS at National Hospital, Abuja three years ago to have the couple’s first child. A vaginal delivery in the same hospital cost a quarter of what he paid for a CS.
The doctors recommended a CS because “the pelvis wasn’t opening well enough for the baby to come out,” he says.
That first CS became an indicator for another CS for their second child-even though his wife wanted a vaginal delivery.
“I saw it as there is nothing I can do. My wife did not like it, and it was taking unnecessary time than expected. I was under duress, there was no alternative.”
Many patients don’t fully understand the indications for a CS.
“I have this feeling some doctors in private hospitals recommend CS because they get more money from the woman and family. If it is a normal delivery, the family will not pay much,” says Nwabueze.
“Sometimes doctors try to convince them that CS is okay; they refuse and still deliver normally.
“My wife wanted to do that. They wanted to take her to the theatre, but she refused. After three days, when nothing was coming out, I had to tell her to just go ahead,” he recalls.
When the option for a CS was mooted for Mercy Abraham, she had already reached the point where she was comfortable with it. She had been in labour for three days, but it “didn’t progress beyond a certain level,” she recalls.
“They monitored the baby and found it was distressed. Somehow I knew. They didn’t tell me initially, but I could see they were worried,” Abraham says of her doctors.
“I could see the worry in their face. I was saying in my mind that if they asked me, I will ask for a CS, because by then I was tired.”
One in three women undergoing a CS get their information from their doctor, researchers point out, but that doesn’t support the sense that doctors are tossing out suggestions for a CS to cut time and just get things done-or to rake more money into hospital coffers.
“Previously, the manpower was not available for CS. Few people were able to conduct a CS,” says Arinze.
“Now that the manpower is there, there is no need passing women through a very difficult delivery, whereas you can just go in, section and bring out the baby.
“On the other part, there are indications a doctor will see during antenatal and opt for a CS. For instance, when you have a CS and come pregnant again less than 18 months of delivery.
“The previous scar is not yet [properly healed], and there is a strong indication your next delivery will be a CS.
“If you are on the small side and a scan is done and they see your baby is big, there is going to be a problem. It is our obligation to start prompting you right from antenatal that you might not have a vaginal delivery. CS might be your best option.”
That prompt works with many couples. After birth complications when his first child was born, Donald Essien has “no qualms” about any woman in his life undergoing a CS to have a baby.
Complications of the cervix threatened to cost the life of his first child. It was fixed four years ago. The couple’s third child comes along in a couple of months, and they have opted for a CS.
“I have no qualms about it. Right now, it is very safe. I understand that there are some women who actually check themselves in to undergo it,” he says.
“It is normal. The level of expertise we have got with gynaecologists, they tend to know what they are doing.”
Just one catch. “It is more comfortable when a woman opts for it herself,” says Essien.
“It is scary when a surgeon suggests it. It gives the feeling something is wrong, but when a woman wants it herself, it feels good as a decision she makes for herself.”
When Kayode demanded her CS, she was 33, and families in her region of the country still considered CS “isiabe” in Yoruba. Mothers cried to hear it for their daughters or daughters-in-law.
Dayo recalls her mother bursting into tears and lamenting, “That small girl, why will they do that to her? Now they say ‘she gave birth, it was through CS, but thank God mother and baby are fine’,” she says.
Years from when Kayode boldly demanded a CS, a lot is changing. Kayode’s baby is five years old this year.