Controversy: Caesarian Section, the rule or option?

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THE joy of every woman is to deliver her baby normally. This is in spite of the many travails associated with pregnancy and delivery. Before now, the most available or preferred option for most women is natural birth. As the world recorded countless maternal deaths due to this process, scientists sought an alternative and came up with the Caesarean Section, CS.

Today, many babies have been delivered successfully through this process. But this success story is not without criticisms. In fact, this life-saving option has become a subject of controversy. How be it, a good number of women now claim CS is now an option explored by doctors to extort huge delivery bills.  Chioma Obinna, Features Writer (Health) reports.

THE fears and myths: EVELYN Obi, a 28-year-old mother of two, did not bargain for a CS.  According to her, having a baby through CS was part of her dream.  ”It is unthinkable. When I was pregnant, there was no sign that anything was wrong with the position of the baby. I was only told the day labour began that I was to have a CS. When I asked why, I was told my baby was not lying properly.

“I was devastated because I had my antenatal services in the same hospital. I could not tell any of my friends. To make matter worse, my husband could not afford the required cost of surgery.  The hospital did not leave us with any choice.  We were ready to borrow even from our enemies.”

Asked why she described it as an unthinkable venture, Evelyn said: “Where I come from, having babies outside the natural way is a taboo. You don’t talk about it. Such women are considered weaklings. We later went to another hospital where I had a normal delivery.”

File photo: Surgeons at work

File photo: Surgeons at work

Evelyn is not alone, Mrs. Ifeoma Agwu, a mother of two, also exploded when asked if she would opt for a CS  over the natural  delivery process. “If I had known that some hospitals are now making CS a business venture, I would have inquired from another hospital before settling for it.

“I must not deny the fact that CS is important in child delivery but not in all cases. When I was pregnant for my second child, I was advised to have a CS since my first child was through CS but I refused.  At that point, a friend of mine introduced me to a midwife who delivered me of my baby without complications.”

Ifeoma who was apprehensive over the alarming rate of CS among Nigerian women said: “I think CS has become brisk business for medical doctors in Nigeria”.

But for six-month pregnant  Mrs. Ope Ige,the story is different as she preferred to have all her children through CS rather than suffer the pains that come with natural delivery.

According to her: “I have three children through CS and I don’t think I can bear the pains of pushing a baby.  I see it as a suicide mission”.

There is an alarm in the reproductive health circle. Investigations have shown that CS has taken over. Available reports have shown that having babies through the natural process is on the decline.

Within the African setting, having babies through the natural process is seen as a show of strength. So,  when a woman cannot do so, she is seen as a weakling.  Her friends mock her as a result, members of the family keep mute over the matter. In fact, such is the secrecy, it is rated as a mortal sin. Today, however, thanks to technology, all that has changed but not without the controversy CS is beginning to generate.

Caesarean section or delivery also known as C-section is a birth through an incision in the abdominal wall (laparotomy) and uterus (hysterotomy) rather than through the vagina.  CS is performed whenever abnormal conditions complicate labour and vaginal delivery, threatening the life or health of the mother, the baby or both. Doctors basically recommend CS when an expectant mother is experiencing a difficult labour.

Caesarean delivery

According to the Centers for Disease Control and Prevention, CDC, there has been a gradual increase in caesarean births over the past 30 years. In November of 2005, the Centers for Disease Control and Prevention, CDC, reported the national caesarean birth rate was the highest ever at 29.1 percent in the United States, which is over a quarter of all deliveries. This means that more than one in  four women are likely to experience a cesarean delivery. But the World Health Organisation, WHO, has stated that the caesarean rate higher than 10-15 percent is unnecessary regardless of location.

In Nigeria, also a study carried out on Caesarean Section in a secondary health hospital in Awka, by the Department of Obstetrics and Gynaecology, Amaku General Hospital, Awka, Anambra State by LC Ikeako1 and colleagues in 2009 showed a gradual yearly increase in rate from 9.0 percent in 2005 to 11.4 percent in 2009. Maternal mortality rate was 480 per 100,000 deliveries, while the prenatal mortality rate was 63.8 per 1000 total births.

Vanguard Features, VF, learnt that apart from difficult labour, doctors often advise mothers who have had previous C-section to have it again. This action has made many women wary of the technology.   Most of the women are of the view that enough options are not being given to them by the doctors.

Apparently due to the demonisation of CS in the country, some of the women who responded to VF also expressed worry on the way and manner some medical doctors handle issues regarding CS in the country.  Others are of the opinion that they were not well counseled on why they should under go a C-section. Still, some alleged that many of the doctors are usually in a hurry to have it done.

VF investigations reveal that many pregnant women would not even give the caesarean section option a thought during delivery. Some told VF that they would prefer to go through labour pains that come with natural delivery and forget about it once their baby is delivered than go through weeks of recovery that comes with caesarean section.

Rita Eke said: “My mother gave birth naturally and that has been our culture. She did not experience any problem during her child-bearing years. These things are better done abroad where there are facilities. Have you forgotten the environment we are in?  Electricity supply is not constant and there is also the fear of infection. No woman should gamble with her life.  I refused to risk my life. I will have my babies like my parents did.”

But many like Jane Ojo, however, is of the opinion that: “If my younger sister, Grace, had listened to her doctor’s advice for a C- Section when it was discovered that her pelvis was too narrow to have a safe vaginal delivery, she would still have been alive today. But she bluntly refused, insisting that she would have her baby through vaginal delivery.

“Despite the pressure mounted on her by the hospital where she registered she refused. She went to another hospital and was allowed to have her way. In the process of having the baby she died.”

Another mother of three, Juliana Jones, said: “I could have been a proud mother of four children today if I had accepted to have my first baby through CS. After two days, of  agonising labour without success, I was wheeled into the labour room for CS but then, it was too late to save the baby but a narrow escape for me. I’m alive but the baby did not make it”.

The facts: Dismissing insinuations on the safety of CS, he said: “Caesarian section is very safe if it is done in the right place by the right person and with right infrastructure in place.”

Also acknowledging the fears expressed by some of the women, he said: “The fears of the women are real because it is safer to have your baby naturally than a C-section, especially in a country where the infrastructure is not controlled. Maternal mortality is very high in Nigeria and there are many reasons for that and one of the reasons is that we don’t have clear bench marks for the facilities that provide emergency obstetric care.

Emergency obstetric care

“There should be a clear bench mark which says before you can deliver a baby in this facility you must have this kind of infrastructure in place. So if we have that kind of infrastructure in place, I think we would allay the anxiety of some of these women.  Anybody can have a room and say I am doing a CS. Until we have that kind of control we will continue to lose women.”

Also a surgeon with the Lagos State University Teaching Hospital, LASUTH, Dr. Olugbenga Saliu Oseni, described CS as an interventional delivery process whereby you have complicated delivery. According to him, it is sometimes the only option left to save the life of mother and child.

On situations that could warrant CS, he said: “The best thing to happen to a woman is to have a normal delivery but when this is not available, the preferred option should be CS because you can evaluate your result”.

According to him: “There are many reasons why a doctor should prescribe CS and some occur in critical situations. Others are used to prevent critical situations and some are elective.  CS can occur when placenta lies low in the uterus and partially or completely covers the cervix.  One in every 200 pregnant women will experience placenta previa during their third trimester.

“Again, placenta abruption could also cause a doctor to prescribe CS. It is the separation of the placenta from the uterine lining that usually occurs in the third trimester. Approximately one percent of all pregnant women will experience placenta abruption. In approximately one in every 1,500 births, the uterus tears during pregnancy or labour.

This can lead to haemorrhaging in the mother and interfere with the baby’s oxygen supply. This is a reason for immediate caesarean.  The position of the baby could also lead to CS. When dealing with a breech baby, a caesarean delivery is often the only option, although a vaginal delivery can be done under certain circumstances.

“Also, cord pro lapse is another cause; it occurs when the umbilical cord slips through the cervix and protrude from the vagina before the baby is born. When the uterus contracts, it causes pressure on the umbilical cord which diminishes the blood flow to the baby.  Sometimes, we do have women who are small in stature or  are in the border line. It is obvious such women can go through normal delivery.

Fetal distress

“Another reason is fetal distress. If fetal monitoring detects a problem with the amount of oxygen that the baby is receiving, then an emergency caesarean may be performed; failure to progress in labour: this can occur when the cervix has not dilated completely, labour has slowed down or stopped, or the baby is not in an optimal delivery position.

Ninety percent of  women who have had a caesarean are candidates for a vaginal birth after caesarean for their next birth. Cephalo pelvic disproportion, active genital herpes, diabetes increase chances of caesarean as well as pre-eclampsia, that is high blood pressure in pregnancy, birth defects and multiple births amongst others,” he added.

Dismissing beliefs that doctors are recommending CS in order to make more money from patients, Oseni said: “It will be crazy for any doctor to think he wants to do CS because he wants to make more money; that means that person is not an expert.  I know that when I want to do surgery I lose appetite. You can still collect the same amount for CS for normal delivery because there are some normal deliveries that are even worse than CS. So that is an idea people do have in their head.

CS is an emergency when you did not expect it and you need to intervene urgently.  It is elective when you know that the baby must come through CS. For instance, an elderly person who has suffered  infertility for a long time and is having a baby for the first time; we call such babies ‘precious baby’ and we don’t want anything to happen to them. So you want  to electively deliver them by CS.

Hypertension or pre-eclampsia

Elective CS is safer than emergency CS because everything is okay when you do elective. But in case of emergency, the patient may have some other abnormalities like hypertension or pre-eclampsia.  Sometimes we deliver them if they are progressing well. Hardly will one die because of an operation. Death arises from either the patient  and relatives.”

He explained that from experience many of the patients who were advised to have CS and they refused and ran away from the hospital usually come back to the hospital with more complicated cases such as inability to conceive again, loss of child, amongst others.

Oseni argued that studies have shown that some babies delivered by Caesarean Section have a better IQ because they did not go through stress of delivery.

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