African women need ac­cess to Cae­sars

Ma­ter­nal mor­tal­ity rates could be re­duced if this surgery was widely avail­able, write Salome Maswime and Gwinyai Ma­sukume

CityPress - - Voices -

Cae­sarean sec­tions (C-sec­tions) have been life-sav­ing pro­ce­dures for thou­sands of women the world over who ex­pe­ri­ence com­pli­ca­tions dur­ing labour. Glob­ally, it is es­ti­mated that just less than 20% of births take place via C-sec­tion – a per­cent­age that has risen over the past three decades. This has raised con­cern, par­tic­u­larly in high-in­come coun­tries where, gen­er­ally, too many of th­ese surg­eries are per­formed.

But in many African coun­tries, women who are med­i­cally re­quired to have C-sec­tions are un­able to ac­cess them. There are several rea­sons for this, the main ones be­ing weak health sys­tems and a lack of re­sources.

Women in sub-Sa­ha­ran Africa suf­fer the high­est ma­ter­nal mor­tal­ity rates in the world. For every 100 000 ba­bies born, close on 550 women die. This amounts to 200 000 ma­ter­nal deaths a year – or two-thirds of all ma­ter­nal deaths a year world­wide.

Some of th­ese deaths could be pre­vented if skilled health per­son­nel could per­form C-sec­tions safely. But this would re­quire proper equip­ment and sup­plies, in­clud­ing drugs and blood trans­fu­sions.

Re­search shows that low-in­come coun­tries with the low­est C-sec­tion rates also have the high­est ma­ter­nal mor­tal­ity rates. Hence, im­prov­ing the ac­cess and avail­abil­ity of this surgery on the con­ti­nent is piv­otal to re­duc­ing the num­ber of ma­ter­nal deaths and achiev­ing the sus­tain­able de­vel­op­ment goal – one of 17 goals spear­headed by the UN – of re­duc­ing ma­ter­nal deaths to less than 70 per 100 000 live births by 2030.

Be­tween 1990 and 2015, ma­ter­nal mor­tal­ity rates dropped by about 44% across the world, while several African coun­tries halved their rates. In Mali, for ex­am­ple, 1 010 women died for every 100 000 ba­bies born in 1990. By 2015, this fig­ure dropped to 587.

De­spite this, more than 800 women con­tinue to die from pre­ventable causes re­sult­ing from child­birth every day – most of them in sub-Sa­ha­ran Africa and south Asia. And mil­lions more will suf­fer com­pli­ca­tions be­cause of in­suf­fi­cient and in­ad­e­quate treat­ment.

The World Health Or­gan­i­sa­tion has found that in coun­tries where at least 10% of women have C-sec­tions, the num­bers of ma­ter­nal and new­born deaths de­crease.

It has not iden­ti­fied an ideal C-sec­tion rate, but there is ev­i­dence that rates of more than 20% in a coun­try may be too high. De­spite this, it en­cour­ages gov­ern­ments to provide the pro­ce­dure to women who need it.

Africa has the low­est C-sec­tion rate in the world. In Europe, about a quar­ter of births are con­ducted this way, and in Latin Amer­ica and the Caribbean, the rate is 40.5%.

In Africa, only 7.3% of ba­bies are born via this method, but it is a mixed pic­ture across the con­ti­nent. Some coun­tries have high Cae­sar rates: Egypt, at 51.8%, and Mau­ri­tius, at 47%, have the high­est in Africa.

De­spite a 2.9% in­crease in C-sec­tions across the con­ti­nent from 1990, there has been a de­cline in some coun­tries, such as Nige­ria and Guinea, where 2% of th­ese surg­eries oc­cur. Zim­babwe has main­tained its rates at 6%.

WHEN CAE­SARS MAT­TER

C-sec­tions of­ten hap­pen at the end of a se­ries of com­plex events. There can be pre-ex­ist­ing and preg­nancy-re­lated com­pli­ca­tions. The need for Cae­sars can be ex­ac­er­bated by de­lays in ac­cess­ing the appropriate level of care, trans­port de­lays and a short­age of nec­es­sary tech­nolo­gies.

Com­pli­ca­tions re­quire prompt ac­cess to qual­ity ob­stet­ric ser­vices, which may include life-sav­ing drugs, blood trans­fu­sions or other sur­gi­cal in­ter­ven­tions.

But there are several bar­ri­ers to im­prov­ing C-sec­tion rates. Th­ese include:

A short­age of mid­wives, ob­ste­tri­cians, anaes­thetists, and lab­o­ra­tory and other al­lied per­son­nel; Lim­ited ac­cess to health care and in­for­ma­tion; and A lack of equip­ment.

Cost is an­other big bar­rier. It was es­ti­mated, al­most a decade ago, that it would cost $430 mil­lion (R5.6 bil­lion) to per­form the 3 mil­lion ad­di­tional Cae­sars needed.

While re­duc­ing un­nec­es­sary C-sec­tions may be a pri­or­ity in high-in­come coun­tries, ac­cess to them will save more lives in coun­tries where de­liv­er­ies in a health­care fa­cil­ity are con­sid­ered a lux­ury.

Many African coun­tries are try­ing to in­crease the num­bers of de­liv­er­ies in health­care fa­cil­i­ties, with skilled per­son­nel in at­ten­dance. In Africa, more than 40% of births are not at­tended by a skilled health provider.

In­equities in ac­cess to C-sec­tions across dif­fer­ent parts of sub-Sa­ha­ran Africa and other low-in­come coun­tries need to be ad­dressed, fast, to re­duce th­ese un­ac­cept­ably high ma­ter­nal mor­tal­ity rates. Maswime is a lec­turer in ob­stet­rics and gy­nae­col­ogy at

Univer­sity of the Wit­wa­ter­srand and Ma­sukume is a med­i­cal doc­tor, epi­demi­ol­o­gist and bio­statis­ti­cian at Univer­sity Col­lege Cork in Ire­land

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