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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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