There is a reported rising cases of caesarean section in Nigeria, but the question being raised by experts is if there is need for the surge amidst demands by modern-day mothers to maintain a firm genital organ after childbirth and the huge financial gains for hospitals. JOHN ADEGWU reports
Recent studies have shown that there has been a growing trend of births by caesarean section in Nigeria, a surgical obstetric procedure medically conducted to save the lives of a mother and her baby when natural birth procedure seems to put them at risk.
Although giving birth by caesarean section is medically proven to be effective and successful in many cases across the world as it has reduced maternal mortality rates and perinatal morbidity mostly in developing countries. However, the World Health Organisation, WHO, advised that caesarean operations should be carried out based on medical justification. It also warned that the rates that exceed the recommendation do more harm than good for a country’s maternal health.
A research professor of obstetrics, Afe Babalola University Ado Ekiti who doubles as the CMD, Louismed Specialist Hospital Lekki, Lagos, Prof A. Bamigboye, told LEADERSHIP Weekend that an increased rate of births by caesarean section has become a great concern in the global health community.
Prof Bamigboye said in most African countries including Nigeria, caesarean section operations had jumped from 25 to 70 per cent, he attributed the reason in the high increase by women who shy away from a natural birth and the need to avoid litigation from birth-related complications.
He said increase in cesarean sections was a great concern worldwide, adding that many modern-day women shy away from natural birth because they are terrified.
According to him, “the increase in caesarean sections is of great concern worldwide and Nigeria is no exception. Cesarean section rate is somewhere between 25 and 70 per cent of childbirths in most African countries at the moment. Many opt for cesarean section based on this fear. The erroneous belief that it will damage the genital organ thereby negatively impacted on sexual gratification is also a reason.
“Emergency caesarean section is also increasing as obstetricians are wary of litigations and we rather believe that a controlled delivery is legally safer than a normal birth,” Bamigboye said.
He further explained that caesarean sections are economically demanding and also come with risks.
“The increased rate of morbidity in the placenta or after birth being situated abnormally is extremely high. The adherent placental is also a common problem that can affect after the pregnancy operation. After the operation, the mother can be sick from the procedure, and there could be an infection, also there could be major blood loss,” he said.
A mother of two, Mrs Katherine Thomas told LEADERSHIP Weekend that she was seven-month-old pregnant when her scanning result revealed that her foetus was in cephalic position. She said from that time, she knew that the major task ahead was to ‘push’ and deliver just like her first baby which she said she gave birth to three years ago.
Two months later during antenatal, she said there was a mild twist in the hospital and the doctor booked her for a caesarean section without her consent.
“I went for my antenatal care that day. I was not yet in labour. I mean I was fine; I have been going there regularly but, on that day, when I came to the hospital, the doctor told me without any examination that I was overdue for delivery. He picked his phone at that moment and started calling his colleagues. I overheard him saying ‘there is an elective caesarean section case here’ which I never booked. I was very scared.
“At first I thought he was talking about a different patient, but I realized that he was talking about me when he dropped the call and told the nurse on duty not to allow me to eat anything until 6 pm in preparation for the operation. Just like that? I was shocked.”
She said she was moody but was assured by the nurse that she would be fine. This happened without the doctor knowing. And she gave birth without going through CS.
Mrs Thomas added that she was glad that she gave birth to her baby before the time given to her for the caesarean section.
According to her, “My husband was not even around, I thought as I sat there somehow confused. The nurse saw my moody countenance and told me not to worry that if I was feeling fine, I would give birth without CS. At that time my positive energy was restored, and I went home. The following day I went to the hospital around 9 am when the doctor saw me and told me I had from now till 11 am for the operation to commence. Not quite long from that time I saw him dressed in theatre attires, preparing for the operation. He wrote drugs worth N30,000 and other operational equipment amounting to N70,000 with the sum of N105,000 inventory for me. I was wondering how I can afford that. At exactly 10:25 am, as God will have it, I delivered my baby boy without much stress,” Mrs Thomas said.
Meanwhile, LEADERSHIP Weekend gathered that many modern-day mothers, in a desperate effort to stay firm even after childbirth, are now o for caesarean section even when there is no need for it. Their argument is simple, caesarean offers them the option of escaping all the pains associated with normal childbirth. Such expectant mothers believe CS helps them to preserve the birth canal from the tears and wears of squeezing out a baby naturally.
A businesswoman and mother of one, Chinwe Nnadi said, ‘’My experience with caesarean was worth it. A lot of women have lost their lives because of prolonged labour. But my caesarean was fast and before you knew it my baby was out. My scar has healed, and you can’t even tell I gave birth through caesarean.
‘’A lot of women believe that caesarean can be scheduled and is quick in comparison to most labour deliveries. This is also reinforced as we live in an age when the quicker methods can be achieved to be more advantageous as it is perceived to be,’’ she added.
But Kate Oge, while narrating the sad ordeal of her friend who after going through hours of prolonged labour in the process of childbirth to LEADERSHIP Weekend said, “the baby’s arms were pulled out of his joint and after all of the pains, she lost the baby and almost her life too.’’
She said if she happens to be confronted with such a choice, she would definitely opt for a caesarean to save her child.
Meanwhile, Anyanwu Sandra Mma said “It is very true. Going under the blade now is a choice.”
A man who wouldn’t want his name mentioned relayed the story of his friend who complains endlessly to him about the expansion of his wife’s vagina after giving birth due to poor medical handling. He said he wouldn’t want anything to tamper with his wife’s elasticity and may always opt for caesarean section henceforth.
Also, a businessman, Stanley Uchechukwu, said he will always pray to God to allow his wife to give birth via normal birth and not through caesarean section.
In their research, Gina Lowdon and Debbie Chippington Derrick of Caesarean Birth Information Report on the phenomenon of maternal requests for caesarean sections said: “A caesarean is clean. The antiseptic nature of the operating theatre is very different from the physical exertion of labour. No sweat and tears. The mess of amniotic fluid and blood is dealt with out of sight. Urine is catheterised. There are no lumps of poo emerging from the rectum, pushed out by the baby’s head as its journey’s down the vagina. Is this not more in keeping with our aseptic society?”
After a random sampling, some Nigerians said that women who opt for caesarean are selfish and lazy seeking the easiest way out. They believe that natural birth still remains the best.
A mother of two, Yewande Badmos said, ‘’I would prefer to go under the knife,’’ she said, adding that “have you experienced it? I haven’t said there’s no pain at all like vagina birth. It’s just not the way people exaggerate about it. I have done it twice, and I’ll choose it again and again over a vagina birth.
A teacher, Aminat Musa, when asked if women who ask for caesarean are selfish, she replied, “I don’t think they are selfish. It is their choice to make, but I do think they need to address the real issue (their fear) rather than run. Just like many contemporary women are opting out for caesarean a lot of women said that it is an “accomplishment” for a woman to give birth through normal birth insisting that it is still the best.
According to Mary Bertrand Arrey, the pain one experiences after a caesarean is much compared to normal birth. In a normal birth, the pain disappears once the baby is out but in caesarean the pain is there for a long time.
Medically, it is believed that babies born via normal birth have a lower risk of respiratory problems. It is widely accepted that the contractions of labour help prepare the baby’s lungs to breathe air. Babies born by caesarean section have a higher risk of respiratory distress syndrome than babies born vaginally at the same gestational age. Adults with asthma are more likely to have been delivered by caesarean section compared with adults without asthma.
Nigeria’s caesarean section rates, empirical findings and WHO recommendations
According to the WHO, births by caesarean section should only be undertaken when medically justified and deemed necessary. WHO recommends that the rate of caesarean section in a country should vary from the minimum of five per cent and not exceed 15 per cent. Thus, rates that are more than 15 per cent are considered to cause more harm than good. There are also warnings from health experts that caesarean section is more likely than natural births to cause health problems for the mother and the baby.
Although rising cases of births by caesarean section differ between regions in Nigeria due to cultural and religious beliefs and as well, access to medical technology and availability of experienced health workers.
Generally, caesarean section births in Nigeria have risen from 6.4 per cent to 33.5 per cent of total deliveries according to a study published in the International Journal of Medical Health and Development in 2017. The progressing rates are also found in Ilorin of 18.3 per cent, 18.5 per cent in Minna and 34.6 percent in Lagos.
Some reports from previous studies have shown a rising trend in caesarean section rate of 10.4 per cent in 1989, 25.3 per cent in 2005 and 27.6 per cent in 2011.
A study conducted in the Ahmadu Bello University Teaching Hospital (ABUTH) Zaria over five years and published in Tropical Journal of Obstetrics and Gynecology 2017, revealed that of 9,388 deliveries during the period, 2,254 out of them representing 24.5 per cent were births by caesarean section.
A retrospective study of six years using clinical information from labour ward logbooks and case records was carried out to examine and validate claims of rising births by caesarean section in Ladoke Akintola University of Technology Teaching Hospital, Osogbo South-Western Nigeria and published in the Open Journal of Obstetrics and Gynecology. The study found that caesarean section rate was 35.5 per cent, with an upward trend. There were 2,798 deliveries of which 1,004 caesarean sections were recorded, putting the percentage above the limit recommendation of 15 per cent for a country by WHO.
In South-Eastern Nigeria, a study was conducted to determine the CS rate and its outcome at the University of Nigeria Teaching Hospital, Enugu for 12 months in which 998 deliveries were made and 256 of them representing 25.7 per cent were by caesarean section. The study was published in 2017 by the International Journal of Medical Health and Development.
In North-Eastern Nigeria, a retrospective study was carried out to determine the rising trend and indications of the Caesarean Section performed at The University of Maiduguri Teaching Hospital. The studies reported in Annals of African Medicine revealed a steady increase of 7.2 per cent to 13.95 per cent in 2005. During this period, there were 10097 of which 1192 were birthed by caesarean section.
When is caesarean section necessary?
Generally, birth by Caesarean Section may be recommended if elective by a pregnant woman or if medically justified by a medical practitioner that vaginal birth will pose a risk to the mother or her baby. LEADERSHIP Weekend findings also revealed that some women choose caesarean section for non-medical reasons.
In some cases, the medically justified conditions for caesarean section operations include when a baby is in breech position and failed attempt by doctors to reposition it, a record of previous birth by caesarean section, when a woman has pregnancy-related high blood pressure also known as pre-eclampsia, when the woman has certain infections in pregnancy and when in prolonged labour or there is an excessive vagina bleeding during labour. As such, when the need arises for caesarean section operation, there should be effective communication between the health workers and pregnant women, weighing the options, risks and benefits.
Medical experts advised that births by caesarean section should be the last resort especially for women who are giving births for the first time. Empirical evidence from WHO findings show no evidence that CS delivery has any benefits for women or infants who do not require the procedure.
“The normal indication for cesarean section may include conditions where the baby is needed to be born immediately. For instance, fetal distress, a condition where the passage is too small for the baby. Sometimes where there is a breech presentation, the option is to give birth by caesarean section. Such conditions demand absolute justification as stated above.
‘’In terms of ethics, the indication must be valid. There may be an edited information process, there must be an ability to handle the communication which may ensure from the procedure,” Dr Bamigboye said.
WHO also asserted that the standard practice for safe labour and delivery practices that reduce adverse outcomes for mothers, fetuses, and babies, is for women to deliver in a facility with a skilled birth attendant and access to quality comprehensive emergency obstetrical care. It implies that there should be political will for a quality health care system and infrastructural development that will enable obstetricians, professional organisations, Ministry of Health to establish evidence-based guidelines for the provision of safe birth by caesarean section in Nigeria in the future.
The upsurge of births by caesarean section is a global trend, a study published in the International Journal of Medical and Health Development revealed that majority of the factors responsible for the high rate of caesarean section includes: ‘’improvement in surgical technique and quality of anesthesia, increased rate of assisted reproductive technology and multiple pregnancies coupled with an increased rate of electronic fetal monitoring and defensive practice. The study also reported financial gain and poor decision making by the health providers as other factors accounted for the high rise of cases of caesarean section operation in Nigeria.‘’
Ironically, it is believed that many women in Nigeria elect caesarean section to escape the pains of labor while others are of the view that giving birth by caesarean section is against their culture and religion.