African women need access to Caesars
Maternal mortality rates could be reduced if this surgery was widely available, write Salome Maswime and Gwinyai Masukume
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