…..Rising cases of Caesarean Section in Nigeria
…..It’s a matter of cash, monetary gain — Critics
…..It’s a matter of exigency, necessity – Health professionals
By Sola Ogundipe& Ebele Orakpo
MRS. Anne Ifeduba(not real name), a 30-year-old banker, was expecting her first baby. Although she was very happy about becoming a mother after a long and emotionally excruciating wait, the stories she had heard about labour pains were of concern to her.
She was told that the closest pain to labour pain was toothache which she had experienced. As far as she was concerned, it was like going to hell and back. Thus, any pain worse than toothache was definitely not for her.
There and then, she decided she was going to do what doctors call an elective Caesarean Section, CS, also known as C-Section, reasoning that no matter the cons, it would be better than going through pains for hours and living with fear that in the end, something may go wrong with her or the baby or both for that matter!
Reminded that as a young woman who may want more than three children, CS may not be the best, she still stuck to her gun, saying no right thinking person plans to have more than three children in today’s world.
Moreover, she was not ready to go through the vigorous exercise needed to get her back to shape after childbirth, because with CS, the belly fat could be removed as the baby is removed.
But this was not the case with Mrs Tinu Thomas, a 40-year-old expectant mother who said she preferred to have her baby the natural way though her doctor advised her to do CS because of her age and some medical conditions.
She would hear none of that. Her reason? She was given birth to in the natural way and she believes that was the best way, the way God made it; so why go against nature? She insisted on giving birth naturally because she believed that doing otherwise would have repercussions. She did eventually, but it was a most traumatic experience as the labour was long.
Mrs Bose Ayinde had been married for 10 years and eventually got pregnant with triplets. It was a turbulent time for her. For six months at a stretch, she was on bed rest. Her strength was going, she could not eat well and her blood pressure was high most of the time. At the seventh month, she knew she could no longer go on; the doctors knew that too, so she was taken for emergency CS.
Mrs. Biola Fakeye’s first pregnancy was in the 38th week when she had a CS. The obstetrician made a narrow horizontal incision in the lower region of her abdomen after an anaesthesiologist had injected a strong analgesic into her spine. Biola did not feel a thing, even as the doctor cut through her skin, large abdominal muscle and into her uterus.
The baby, a girl, was pulled out feet first. Her shrill cry was the big relief Biola had longed to hear in the past nine months. The whole procedure was over in minutes. Another successful C-section had been carried out. Modern obstetric care had succeeded. Mother and baby were in perfect condition and were discharged just over a week later.
Over the next five years, Biola had two more pregnancies and went through a C-section each time to give birth to three healthy children. None of her pregnancies was in any way complicated, so Biola has no regrets that the surgeries were by choice rather than medically advised.
When Chiamaka Ndu was advised to consider having a C-section instead of a vaginal birth, it was a shock and she was initially hesitant. It was her first pregnancy and she had never expected a C-section. In fact, there had never been any C-section in her family. Her mother had six children, including a set of twins, and did not give birth through C-section. Chiamaka had thought when it came to childbirth, it would be done naturally like her mother and grandmother before her. So, it was rather shocking when the doctor suggested a C-section for her.
But the doctor was emphatic. Chiamaka was in the 28th week of pregnancy and hypertensive. For almost two months, she had woken up each morning with throbbing headache, a swollen face and swollen lower limbs (fluid retention). Her blood pressure was abnormally high, and tests detected large amounts of protein in her urine (proteinuria).
Dangerous pregnancy complication
According to the doctor, these were classic symptoms for pregnancy-induced hypertension also known as Preeclampsia – a dangerous pregnancy complication only relieved by birth of the foetus or termination of the pregnancy. Chiamaka was placed on powerful anti-hypertensives and confined to permanent bed rest. Her doctor explained that because of the high risk, attempting a vaginal birth was not advisable, and that a C-section was the safest bet. Three weeks later, she had the surgery. Her baby, a boy, though premature, was healthy. He was placed in an incubator while she fully recovered from the procedure. Once again, modern obstetric care triumphed where nature failed.
Welcome to the world of women with the complex and indeed uncertain choice of delivering their babies naturally or through C-section or CS as it is more popularly known.
In the past few years, cases of CS have been on the increase with some women alleging that doctors often force them to undergo CS instead of vaginal birth.
CS is defined as the delivery of a baby through a surgical incision in the mother’s abdomen and uterus. CS could be elective where a pregnant woman chooses to deliver through CS, especially when it is not on health grounds or an emergency where the doctor persuades her to undergo CS on health grounds.
In this report, Vanguard INSIGHT sought the opinions of stakeholders in the medical field and also women, on the reasons for the rise in CS cases as against what was obtainable some 20 or 30 years ago.
Rise in CS cases in Nigeria
A FIVE-year survey of Caesarean delivery at the University of Nigeria Teaching Hospital, Ituku Ozalla, Enugu State was carried out by E. Ugwu, K. Obioha, O. Okezie and A. Ugwu from January 1, 2005 to December 31, 2009 and published in the National Centre for Biotechnology Information journal.
According to the survey, “out of 3,554 deliveries during the period, 980 cases were by CS, giving a rate of 27.6%. Most cases, 918 (93.7%) were by emergency CS, with elective procedure accounting only for 6.3% of the cases.
The age range of the women was between 16 and 48 years. Four hundred and seven (41.5%) were primigravidae (first time pregnancies), 503(51.4%) were between para one and para four, while 70 (7.1%) were grand-multipara (women who have already delivered five or more infants).
The rate of CS was higher amongst the booked patients, 563 (57.5%) than the unbooked patients 355 (36.2%). Two previous CS was the commonest indication for CS 211(21.5%), followed by cephalopelvic disproportion 198 (20.2%), and foetal distress 188 (19.2%).
A total of 1,009 babies were delivered through CS by the 980 women; 955 cases of singleton gestations and 25 cases of multiple gestations (21 twins and 4 triplets).
Majority of the babies 918 (91%) were delivered by emergency procedure. More than half of the babies 582(57.7%) had birth asphyxia and there were 39 (3.9%) perinatal deaths. All the cases of perinatal deaths and 549 (94.3%) of birth asphyxia occurred following emergency procedure.
Anaemia was the commonest postpartum morbidity and the maternal case fatality rate was 0.7%.
“In the past 30 years, the incidence has increased from 5% to approximately 25%. The general range is from 5% to 15% with a steady and continued increase during the last two decades in the developed nations up to 30%.
“Efforts made in the last two decades to check this rising incidence include encouraging vaginal births after previous CS, discouraging CS on social indication, use of foetal scalp PH to confirm foetal distress before embarking on CS, among others.
“Despite these, the obstetrician’s low threshold to taking risk precipitated by the ever increasing cases of litigations following poor neonatal outcome, appear to have counteracted the gains made from the above measures,” noted the report.
In another study entitled Caesarean section – an appraisal of some predictive factors in Lagos Nigeria, and published in BioMed Central, Oluwarotimi Ireti Akinola, Adetokunbo O Fabamwo, Adetokunbo O Tayo, Kabiru A Rabiu, Yusuf A Oshodi and Mercy E Alokha identified the factors associated with increase in CS rates to include: previous CS and patients attended by a gynaecologist with more than 16 years of experience, use of electronic foetal monitoring and foetal scalp blood sampling, the use of partograms, breech presentations, extreme ages of reproductive life, macrosomia, nulliparous and grand multiparous status.
“Others include bleeding during pregnancy, high blood pressure, multiple pregnancy, height less than 150 cm, foetal compromise, nulliparity and presence of medical disease during pregnancy, obesity and lack of hospital antenatal care.”
Factors contributing to rise in CS cases
Responding, Dr Omadeli Boyo, Medical Director at Pinecrest Specialist Hospitals, Lagos said that many factors have contributed to the rise in cases of CS.
“One, more people are moving to the urban areas where facilities are available and people now understand that they should not be in labour for too long. They have seen others who were in labour for too long and died, so people are beginning to find out that caesarean sections are pretty successful and the hazards are not as high as before.
“Two, there are more trained people doing CS successfully now even though we still have some instances of death through CS.
“Three, poor antenatal and labour supervision without well-trained personnel usually led to CS in the past, but now, we have a lot of well trained personnel and trained traditional birth attendants who are able to pick up what you may call the red flags early in labour. So, instead of leaving it to chance, people are able to detect some parameters like height, co-existing morbidities like diabetes, severe hypertension and heart failure. There has been stricter monitoring like when you have some existing challenges like your first time being pregnant, multiple pregnancies and high blood pressure, those three together will put you up for CS,” he said.
Close foetal-maternal monitoring
Dr. Olusegun Peter Adebowale, Senior Medical Doctor/Hospital Administrator at Kessington Adebukola Adebutu Foundation, KAAF, University of Lagos, believes that the rise in the cases of CS is due to close foetal-maternal monitoring during antenatal. “Before now, there were no good investigative or normal routine procedures done for pregnant women during antenatal care. Now we have what we call foetal-non-stress test, a procedure given to all pregnant women. If a pregnant woman notices that her baby is not moving very well, she comes for cardiotocography, CTG, a test usually done in the third trimester to check baby’s heart rate. We monitor them for a particular period of time, may be for 20 – 30 minutes and during this period, we read the tracing and are able to give the graphical interpretation of the baby’s heartbeat.
Normal foetal baseline heart rate is between 110 and 160; so anything less than that is called foetal bradycardia, that is, low heart rate; and anything higher than that is called foetal tachycardia. There are some things we look at before we can say a baby is fine or not fine.
“A woman who is 34 weeks pregnant notices that the foetus is not moving well and when she comes, we check her using a hand-held Doppler. If we discover that the foetal heart rate is high, we can send her for further investigation. If you notice there is foetal tachycardia, you may prepare the woman for sectioning.”
Erring on the side of caution
As the saying goes, it is better to be safe than sorry. So a doctor will prefer a woman goes through CS and comes out alive with the baby than face death during labour in which case, the doctor may be sued.
Said Boyo: “With the rise in literacy rate and people getting more and more enlightened, they can challenge doctors in court. So most doctors will prefer to go through the CS route rather than face medico-legal problems.
“If the child or the mother dies, the doctor can be sued. It is now like in the US where CS rates are high because doctors are afraid of the medico-legal implications for allowing a woman die in labour.”
Adebowale on his part said some women decide to do a CS because they wouldn’t want to go through pains. “But you have to let them know the risks so that they won’t say you didn’t tell them. They must sign a consent form because every hospital case now is medico-legal. Apart from that, in our centre, we let them know the risks and try to do the best even if the mother requested a CS.
“With the Coroner’s law in Lagos State, you have to explain every death. Such cases are taken up with the state government; so most doctors will want to ensure that anything they cannot explain or anything that is going to put them in trouble is put out of their way immediately,” stated Boyo.
Why vaginal birth after CS not advisable —Experts
He noted that “the rate of CS is increasing also because doctors have discovered that it is better to err on the side of caution, especially when the issues involved are more than two complexities in a woman.
For example, if a short, smallish teenage pregnant girl comes, you look at whether she can deliver normally. Doctors now do so many things to assess the possibility of the baby coming out on time.
“Many years ago, scan machines were fewer; now you can tell if a baby is overweight. For any baby above 4.5kg (4.0kg in some centres), you just advise the woman to go straight for CS.
“About 30, 40, 50 years ago, people waited and did what we call ‘try your luck,’ or a doctor assessed the weight of the baby based on what he could perceive from the outside and sometimes, they do vaginal examination to check whether the pelvis was adequate. Now, it is easier to say ‘this pelvis is not adequate or it is 50/50, we are going to give you some hours to labour and see whether the baby can go through.”
Vaginal birth after CS not advisable—Boyo
Boyo noted that people now accept that after a previous CS or as a result of a possibly recurrent issue, it is not advisable to deliver vaginally. “For instance, if you have had a previous CS because you are short or your pelvis is inadequate, such people surrender themselves to CS.”
People more enlightened
“People are becoming more enlightened. As bad as the healthcare system is, in Lagos, you see many signboards pointing to health centres here and there. So in Lagos State, for instance, the government has put up more health centres staffed with qualified midwives. There may not be doctors round the clock but these midwives are able to pick and refer them to a general hospital or a teaching hospital.
“So, if they have a recurrent issue like being short or a woman having triplets, most doctors would not want to go through the challenge of waiting to see how it will go; they do not want any foetal wastage. They would want the woman to do a CS so she can have them on time, and everybody is safe.
Elective CS: “The problem is not that these babies cannot come out naturally, but with an elective CS, all would be ready – paediatrician, incubator, anaesthetist and theatre. The woman is also ready psychologically.
“So unlike in those days when the woman was left to fate: she comes in at 2.00am, the laboratory is closed or partially functional, the anaesthetist is not around, you want to look for blood to give at that time of the morning and you won’t get it. But now, with these parameters, a doctor can tell a woman she is going to have an elective CS and some women do agree,” Boyo stated.
Another factor that has contributed to the rise in cases of CS, according to the doctors, is that many older women are getting pregnant these days. “People are having babies at above 40 years – elderly primigravidas. The babies are called precious babies because these women do not intend to have six children; they want to have two and stop because they are already in their 40s. Most women at that age do not want to go through labour because age is not on their side, they don’t want to be embarrassed,” said Boyo.Women not allowed to labour for 48 hours
“Medical practice has reached a point where women are not allowed to labour for two days unlike before. Now, if a woman starts labour and it is an established labour, within eight to12 hours maximum, she should deliver and if she doesn’t, a decision is made. She will have to go through CS. So doctors are trained to watch out for these red flags. In those days, a woman could be in labour for three or four days. No qualified doctor working in a hospital that has facility for CS will allow you stay in labour for so long again.”
Affordability: Boyo pointed at the affordability of CS as another factor. “People can afford CS now even though the economy is so bad. In those days when it was N30,000, people would scream but funny enough, they are able to save for it because they believe in it.
“In most cases, even those who are not prepared for it still manage to get the money from extended family, community, friends etc, when it is emergency. Average private hospital in Lagos now does CS for between N100,000 and N120,000. Some hospitals charge N80,000. A normal birth in most hospitals range from N20,000 to N100,000 depending on the hospital.
“The traditional birth attendants and midwives who have maternity homes charge less; so people now have options,” noted Boyo.
Adebowale said that normal vaginal delivery is between N70,000 and N120,000 while CS is between N300,000 and N350,000.
Are Women ‘forced‘ to do CS for monetary gains?
On the allegation that some doctors force women to undergo CS, Adebowale said although he has heard that some hospitals do that as a means of increasing their profit “but I haven’t seen any. It is totally wrong if it is true. Some women request for CS; it is in their own right. But the doctor should enlighten them.
“These things should be looked into seriously. A doctor should know the reason he/she is called into that profession and they also took an oath, so they must do the right thing at all times . Irrespective of the fact that they are making money from CS, their conscience will be telling them they are doing the wrong thing. These things have a way of coming back to you whether you like it or not.”
Boyo disagrees, saying the word ‘force’ is subjective. “That word ‘force’ is very subjective because if you see a woman that obviously needs CS and has been in labour for 24 to 26 hours and calling the pastors to pray for her, the doctor may let her go somewhere else.
“If that is what they call force, yes it happens. But if it is to say people are being intimidated or manipulated to accept CS, then it will be difficult because if you are going to have a normal delivery, you don’t need a doctor to tell you; labour will progress and within six to eight hours, before they can manipulate you, the baby has come out.
“People say that but that is not totally true. If it happens, it is left for the woman to put the doctor on the hot seat. Ask why you need CS and the doctor has to convince you on these three basic things – the passage (mother), the passenger (baby) and the power.”
Passage, passenger, power
Continued Boyo: “If the woman has hypertension, diabetes, heart failure or some other debilitating conditions, she cannot go through normal delivery; so if you convince her from that angle, she may likely have a CS.
“Some women look big and they tell you they can deliver normally. They don’t know that when we talk about passage, we are talking about the internal bone system of the pelvis.
“Some women have big waists but you will be so surprised that the pelvic outlet (the pelvis is like a basin, it has a top and a bottom) may be so constricted that the baby’s head cannot pass through.
“You have done your examination and measured and seen that this pelvis is small and you talk about CS, the woman begins to wonder what you are talking about because as far as she is concerned, she is big enough.
“There is the issue of cephalopelvic disproportion in some women; the baby’s head may not be synchronous with the maternal pelvis. When you notice this, you may allow the woman go into labour; by the time she gets to a particular stage and you discover she is not progressing, if you check, you may come up with a diagnosis of cephalopelvic disproportion, CPD, ie the baby’s head is not proportionate to the mother’s pelvis and the stress of contractions may not be good for the baby so you may need to put the woman through sectioning,” said Adebowale.
“There are other women who having delivered before, think they should deliver normally now. ‘I had a normal delivery before, so why are you telling me to do CS?’ But now, baby is bigger and she has developed some other health issues. A diabetic woman will likely have a big baby so you watch her for the size of the baby. It is not diabetes that leads to CS, it is diabetes and its complications. So people are not really forced, they are educated/enlightened to take the right decision, especially when labour has progressed for so long.
“Then there is the passenger. How is the baby lying? If the baby is lying across (oblique) for instance, or is lying transverse, there is no other way than CS. But they will tell you that one old woman said you can turn the baby; there is no other way to turn the baby.
“A child may be coming out with the face or they are twins holding themselves as if in an embrace, they cannot come out normally. After explaining to some women, they will tell you they want to try to deliver normally. Of course there is always a pastor down the road that will tell her he saw her deliver normally. So women are not really forced. We educate them to see the need for a CS,” said Boyo.
Adebowale agrees that a breech presentation will end up in CS. “A situation where the baby’s head is up and the bottom down; these are things that killed women in those days as complications of pregnancy.
“These are some of the complications that we did not know but these days, because of advances in technology and other investigative processes that one can actually carry out during antenatal care visit, we discover them on time. The reason you come for antenatal care is not only to check your BP but to look at all the conditions that could pose a risk to you having a successful delivery.
CS comes with risks
“Irrespective of the fact that CS is good, it doesn’t come without risks because anything surgery could have complications. If an inexperienced person gives the epidural, from that table, without even starting the surgery, the patient may die. Every surgery has its own complications; the patient may die from bleeding even before going through the anaesthetics complications,” said Adebowale.
“Sometimes after they reject a CS, they go down to a maternity home and the baby comes out normally and they start laughing at you that you wanted to take their money whereas the doctor was trying to err on the side of caution.
You may have this baby but it may be very tough and if a labour is so prolonged, a baby may not survive it. If it survives, the baby may not cry on time, it may have cerebral palsy and other challenges. So doctors in saying they want labour to be short, are thinking about the health of the baby.
“The power: Some people start labouring and suddenly they cannot contract any more. You set up the hot drip for them and they still don’t labour, you find out that the cervix is dilated, the membranes have ruptured, water has poured and you try everything and labour is not progressing, what do you do?” asked Boyo.
Lifestyle changes: Adebowale also pointed at lifestyle changes as contributing to rise in CS cases. “People now take all sorts of things, they read all sorts of things on the internet. You discover that there is an increase in the incidence of pre-emclampsia, pregnancy-induced hypertension; there could be acute or chronic hypertensive diseases in pregnancy too.
“There could be history of gestation diabetes. A woman who is pregnant can suddenly develop diabetes. Such mothers are prone to having big babies called macrosomic babies. For such women whose blood sugar is not well controlled, after controlling the sugar for some time, you may need to quickly deliver that baby through CS.”
Myomectomy: Another factor, said Adebowale, is women who have had previous gynae procedure. “A woman who has had a previous myomectomy (fibroid surgery) and conceives in less than one and a half years after the surgery, she goes through CS because during labour, the stress of contraction could affect the uterus and that line where the uterus is sutured could rupture and the woman could easily bleed. We have seen people bleed to death as a result.
“Also a woman who is less than 1.54m and having bigger baby is also a candidate for CS.
“A woman who is pregnant and suddenly discovers high blood pressure; if you check her urine for protein and see that the protein is more than 300g in 24 hours; you may need to put her under close foetal-maternal surveillance because the effect of high blood pressure is on the placenta. Pressure helps in effective effusion of the baby through the placenta; so when the blood pressure is too high, that will constrict the vessels and if enough blood oxygen is not supplied to the baby within a particular minute, the baby dies.
“We have had so many cases where some women said they went to hospital and discovered they had high blood pressure issues and one day they slept and discovered that their babies were not moving. By the time they came to the hospital to check, the babies were dead.
That is what is called intra-uterine foetal death and some people didn’t even know they were hypertensive. In those days, these things were not done, there were no reports. Pregnancy was a big risk. A woman who was not hypertensive before suddenly becomes hypertensive because of pregnancy. A woman who was not diabetic before, suddenly becomes diabetic; a woman who is fit before suddenly dies because of pregnancy.
“Some of us in this part of the world still do not know what antenatal care entails. There is something we call pre-conception counselling. Before a woman gets pregnant, she should come to the hospital. Pregnancy should be planned. Some will wait until they miss their period before coming to the hospital; some will not even come until they are about four months pregnant; it should not be so.
Bad obstetrics history: “Pregnancy should be planned for so that at the earliest stage, we can screen the mother and baby for necessary investigations so that they can have a safe and successful delivery. Some people have bad obstetrics history; may be a woman who has had two previous CS and is coming again or a woman who has had one previous CS and is hypertensive, it is an indication to go for CS. We have had so many women who have had previous CS and they delivered the second babies normally so one previous CS is not an indication for a CS.
Underlying risk factors
There is something called vaginal birth after CS. “It is when the interval between the first CS and the second is more than one and a half years, and the mother does not have any underlying risk factors that could pose as a risk to having that safe delivery,” said Adebowale.
Nutrition: Nutrition also plays a role, according to Adebowale. “If in a family, for instance, one of my parents is diabetic, of course I should be very careful what I eat. You discover that because of the high intake of refined diet like ice cream, pizza and genetically-engineered foods that could increase their glycaemic index and could tilt them to having poor sugar control and we know that if our blood sugar is not well controlled, it could increase our chances of becoming hypertensive which could have effect on the heart.