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A Caesarean section is a form of surgery in which one or more incisions are made through a mother’s abdomen and uterus(womb) to deliver her baby(ies).It is usually performed when a vaginal delivery would put the baby’s or mother’s life or health at risk, although in recent times it has been also performed upon request for childbirths that could otherwise have been natural.

While this life saving innovation is helping to save the lives of women and contribute to reducing maternal mortality, it is often a source of stigma especially in Nigeria where some women are sometimes “ashamed” to say they were delivered by CS. Kingsley Obom-Egbulem engaged an expert on this issue . The interview featured questions you’ve always wanted to ask about Cesarean Section with answers presented in a down to earth manner by Oliver Ezechi, Consultant  Obstetrician and Gynecologist and Chief Research Fellow at the Nigerian Institute of Medical Research(NIMR),Lagos.

What are we not doing right with respect to CS in Nigeria and what are your recommendations in addressing these ills?

Presently there are lot of negative perception about CS, with local myth that only weak women deliver by CS. CS is also termed as unnatural. There is also the believe that CS limits the number of children you want to have. With special reasons and in the hand of a qualified obstetrician  4th and 5th CS can be done. The cost of CS is also a major barrier to acceptance of CS. My recommendation is that we need to intensify public enlightenment  on dangers of having children too early, too close and too many children. We need to educate the public on the reasons for embarking on CS. Maternal health services should be free including CS.

What specific  gynecological or obstetrical problems was CS invented to solve and what is the state of this problem before the advent of CS?

Caesarean section was originally invented to save the life of the mother from dying or sustaining injuries from prolonged labour. Later, it was extended to save the baby too.

The Caesarean operation was thought to have originated in Roman times. It is known that Caesar had made a decree under Roman laws that all women who were dying in childbirth should have their baby delivered by cutting open their belly. This was meant as an attempt to save the child and increase the low population at the time. Hence the word ‘Caesarean’ was derived. In the 1500’s a French midwifery text referred to the operation as a ‘section’, making common the term ‘Caesarean section’. Later it became a tool not only to save the life of the  baby but that of the mother too.

Some women by their physical make up  and based on some medical reasons are supposed to have their babies through CS. Could you shed some light on this?

Oliver Ezechi:We must embark on constant education of women and their families what CS really does for them and their babies

The reasons for carrying out CS could be maternal or fetal or both.  For the baby to pass through the birth canal , there needs to be enough power to push it down- uterine contraction, baby small enough (passenger) to pass through the birth canal (passage).

If there is a problem with either the power, the passenger or passage, the baby will not be able to be delivered vaginal. In some women, because of their small size, or injury to the passage ( fracture of the pelvic bone during accidents), deformity from e.g. polio or congenital abnormality of the pelvic bone, the passage is small, a normal sized baby will not be able to pass through. The labour is stalled. Unless  CS is performed to remove the baby, the mother or baby  may die from injury or exhaustion. Also if the baby is too big, or presenting in an abnormal way  it will not be able to pass through a normal passage. Also some women for medical reasons in may not tolerate labour and delivery e.g. hypertension in pregnancy, previous injury to the womb will not be allowed to labour and push as this may cause severe morbidity and mortality.

Within the religious parlance delivery through CS attracts some form of stigma and you hear some women say “when the Doctor told me I am going to have my baby through CS,I rejected it and we started praying and the next thing the baby came out”. What’s behind this  perception of CS?.

In Nigeria some pregnant women will not mind losing a baby than having a CS. If the baby is not doing well during labour, a doctor will recommend CS for the woman to be able to have quality baby . A lot of babies are born compromised. The effects are not manifest until years later when the child starts having problems with learning . At that time it will not be attributed to the difficult delivery.

Do you have a personal experience in this regard?

Sometime ago, I had advised a couple about having a CS because the baby’s heart rate was not doing well during labour. The labour got prolonged as she had a borderline pelvis. They rejected it and discharged themselves against medical advice. Days later the couple came back to the clinic and boldly told me that God did it for them despite my recommendation. She proudly said ‘I had a normal delivery’. They were making mockery of me but  I professionally told them that  if  I have a situation again like theirs, I will do the same thing. As they were leaving I noticed that they did not come in with their baby and I innocently asked ,’were is the baby?’They shamelessly answered that they believed that the baby was not their own as they lost the baby soon after birth. That God will give them their own. The couple lost two other babies in quick succession. They later came to their senses and now have three kids from CS.

There is also the cultural dimension to this CS issue, where women who didn’t  go through vaginal delivery often hide the truth about how their baby was born some even lie and we are told they are said not to have the normal experience of child bearing? What’s your take on that and how can we deconstruct this mindset?.

We need to step up public enlightenment campaigns on the reasons for CS. Empowerment of women to be able to take decisions and free maternal health care. People need to know that CS is life saving option aside helping you have your baby safely and we should not be clapping for people who were told to go CS and they eventually had vaginal delivery, we are sending wrong signals about CS and women who opt for it.

How many times can a woman go for CS?

There is no fixed number. However, for every one after three deliveries ( whether vaginal or CS)  the risk of maternal morbidity and mortality increases. The ideal family size scientifically is two. The safest pregnancy is the second one. However, we generally advise women not have more than 3 CS but in the hands of  qualified obstetrician you can go as high as 5 or 6. I have done a 7th CS. The woman came to me after 5th CS and she had no child and she been advised not  have any more pregnancy. When she came to us we knew if we ask her to go, she may end up in the hands of unqualified persons and get killed. We counseled her on the dangers and agreed with her that she will be admitted in the hospital at  28weeks and delivered at 36weeks instead of 38weeks. We didn’t want her to contract at all because she may rupture her uterus and bleed to death. She has two kids now. After the 7th CS we tied her tubes.

How can we make CS safe or safer given our setting where unsafe surgery is contributing  to medical accidents and swelling the rate of needless deaths?

All maternal deaths in the country should be reported and inquiries made about how the woman died. We should insist that CS is not be performed by people not qualified to do so. Government should improve the capacity (human and infrastructure) of our hospitals to deliver quality services.

How do you prepare a woman who might require CS for surgery?

The woman should be counseled and educated on the reasons for the surgery. She need assurance and support. To increase acceptance, they do not need to be kept in the hospital for 7 days. After CS, I discharge the woman on the third day like any other woman. They come back on the 7th day for me to review the site of operation. This will reduce cost as well as prevent the relations from knowing she had a CS. We did a study in Ile-Ife which showed that our women prefer it and will accept CS in such situation.

The issue of cost  and affordability verses the need to save a woman’s life and that of her child will always pop up whenever we discuss CS in context of reducing maternal mortality. If a doctor knows quite well a woman will require CS and the husband obviously  can’t afford it, where is the fair point to stand?

Government should declare free maternal health  and improve public hospitals. Women who cannot afford the bills of the private hospitals will have a choice. If you go to a private hospital you will have to pay your bill because they receive no subvention from government.

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Dr. Oliver Ezechi is a consultant Obstetrician/Gynecologist and Chief Research Fellow at the Nigerian Institute of Medical Research, NIMR, Lagos where he has made significant contribution towards strengthening the quality  of Prevention of  Parent to Child Transmission(PPTCT) project. Ezechi is also responsible for the Post Exposure Prophylaxis(PEP) Project which involves the management of rape survivors  including helping them prevent HIV and other sexually transmitted infections that may have occurred during rape. He speaks with Kingsley Obom-Egbulem on his work and the spate of sexual violence against women

How did you get involved in handling rape cases/issues..and how has it been so far?

My training as a Gynecologist exposed me to the issues of women health and gender based violence of which rape is one of such issues. Then HIV was not an issue , you only worry about the physical and emotional injuries, treatable sexually transmitted infections   and pregnancy. Because of our culture and laws, these women never reported such cases especially in the public hospital. When I left the teaching hospital and moved over to a high profile hospital,it seems  to me that the numbers were higher.

Ezechi:There's need to examine the role of violence against pregnant women-especially by their partners to marternal mortality

It then dawned on me that because these women are more aware and educated, they tend to report. I then tried to conduct a study on the prevalence of domestic violence among our women. With the awareness about HIV and public enlightenment and by the time I joined the services of NIMR, cases of rape became like any other case.

I had no option than to get involved not only in handling such cases when present, but to train younger colleagues on handling rape and public enlightenment on the issues of rape. I am happy now that at NIMR , I don’t need to be around to handle it as it were in 2004. Now any doctor in NIMR can handle the medical issues involved. However we need to know that  managing rape cases is more than handling the medical issues alone. Emotional and psychological issues are as important , if not more important. It is very challenging.

The absence of reliable data on rape and other forms of sexual violence against women seems to make the issue a silent epidemic in Nigeria. But as someone who attends to rape survivors, how would you describe the issue of rape in Nigeria?

Silent epidemic is the right phrase to describe gender based violence in the country. The question should be why is it a silent epidemic? It is silent because of our culture. No woman or parent wants to report cases of rape because of stigma associated with being raped. Also most rapists are people who are close to the woman.  In the last few years , the pattern of rape have changed , now armed robbers and some psycho deliberately ambush ladies especially the once that leave their houses very early in  the morning.

On average, how many survivors do you attend to on a weekly, monthly or daily basis?

The issue of rape is on the increase. Hardly a day passes now in Lagos without one hearing or reading about a case of rape. As of 2004 in NIMR , you may not even see a case in 6 months. Now we see at least a case in two weeks. Some months back we were even seeing at least a case per week.
As a gynecologist/obstetrician and rape therapist how does the problems of rape and sexual violence affect your patients.

Rape has devastating effect on the physical and mental well being of the survivor. It ranges from loss of self esteem to outright psychiatric consequences. Some survivor have never enjoyed sexual relationship thereafter. The physical consequences ranges from genital injuries to infertility and HIV infection. Infertility resulting from the effect of the acquired STIs on the reproductive organs. Infertility may also results from loss of self esteem and non consummation of marriage as a consequence of rape. Some marriages have broken down because of rape. Some women who found themselves pregnant after rape described it as the worst crisis any human can face. Taking decision about the pregnancy is not easy.

Pregnacy:an awesome dream that can turn into a nightmare for ay woman living with a violent man

There is also the problem of battery especially of pregnant women by their husbands..what is the incidence and its impact on your work?

Domestic violence against pregnant women have been shown to have a negative effect on the outcome of pregnancy. Battered pregnant women tend to have premature delivery and even deliver babies that are too small for their age. As we know, premature delivery and low birth weight babies are major causes of infant mortality and morbidity. Managing battered pregnant women is a very big challenge as most of these women have problem keeping their appointment and taking instructions. Managing their pregnancy, labour and delivery is even more challenging.

*In a study we conducted in 2004 among Five hundred and twenty-two pregnant Nigerians published in Journal of Obstetrics and Gynaecology in the UK, 47.1%  of the women reported history of abuse in their  marriage. 28.7% of the women experienced some form of abuse during current pregnancy. 25% and 14.2% reported physical abuse and forced sex respectively. The spouses were the perpetrators of the abuse in 78.7% of cases. Quite unfortunately 99% of the women never reported the abuse because of associated stigma and fear of reappraisal attack.

Have you ever had cause to meet any perpetrator of sexual violence against your patients  and what was the experience like?

No…I have not because the women never allowed  such meetings to hold.

What are your views about men who violate and abuse their women especially from the point of view of a man who provides therapy for rape survivors.

I have come to realize that it is only a weak man that violates a woman. A man beating a woman is like beating a child because you are beating a defenseless and non threatening person. Studies have shown that abuse of women is a learnt behaviour. A man who grew up in an environment where the father or the uncle beats the mother or aunt is likely to become an abuser. He will grow up believing that wife or girl friend battery is normal. It may also be an outright psychiatric disorders – they enjoy inflicting pain on others or enjoy seeing others suffer.

Rape may also be a way to compensate for their underlying feelings of inadequacy and feeds their issues of mastery, control, strength, authority and capability. In such situation the rapist relies upon verbal threats, intimidation with a weapon, and only uses the amount of force necessary to subdue his victim.

How would you describe your work and what are your challenges?

The work of rape management is challenging as well as frustrating. Most of the survivors show up late when you may not be able to prevent either pregnancy, Sexually Transmitted infections(STI) or HIV. Some of these women are so unfortunate that they first presented to health workers who mismanaged them. For us to be able to help, the survivor must show come to us within 72 hours of the incident.

What are the critical steps to take once a woman has been raped or suffers any form of sexual violence?

The law requires the woman to report to the police first. However, in our environment my advice is for the woman to report to the hospital first, receive the necessary treatment and from there proceed to the police station. Other  crucial step includes:(1)Do not take a bath or change the clothings as this destroys the evidence.(2)Report to a centre that is knowledgeable in handling rape cases.(3)Your doctor may call in the police or you report to the police after the hospital visit.(4)Before you leave the clinic, ensure you see a councilor, receive  drugs to prevent pregnancy, STIs and HIV.

Is there anything genetic about rape?

There is no single theory that conclusively explains the motivation for rape however genetics is not one of them. The motives of rapists can be multi-factorial and are the subject of debate. Three primary emotions are thought to motivate rapists, anger, power and sadism, though sexual gratification and evolutionary pressures are also theorized as factors.

*(Ezechi OC ; Kalu BK ; Ezechi LO ; Nwokoro CA ; Ndububa VI ; Okeke GC. Prevalence and pattern of domestic violence against pregnant Nigerian women. Journal of  Obstetrics and  Gynaecology.  2004; 24(6):652-6)

This article was first published in MANHOOD Magazine,2009 edition

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