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Cesarean Deliveries: Life saving or taboo?

A few years ago, I witnessed a very bizarre birthing session in a private hospital in Ikoyi, Lagos. A seemingly well educated yet frantic pregnant woman had been in labour for over 24 hours as her labour was failing to progress. ‘Failure to Progress’ is a term used in obstetrics and gynaecology to describe prolonged labour, in which the cervix is slow to dilate. This stage of labour is made up of uterine contractions, effacement and dilation of the cervix; and can last from 6 to 12 hours in normal labour, and up to 14 to 20 hours in abnormal labour. After 24 hours, the patient was clearly in a lot of pain, and her baby was in distress.

She vehemently refused all expert advice to proceed with an emergency c-section. After a lot of persuasion from the nurses, she admitted that she had been advised by a spiritual leader to avoid going ‘under the knife’ to birth her child. This counsel was given to her as a result of a ‘dream’ that that said spiritual leader had had prior to her labour. Even while experiencing excruciating pain, she stubbornly refused to listen to the pleas and advice of all the medical professionals, and opted to only heed to the advice of this leader, over the phone. This went on for hours; at some point she even refused to be assessed, but also refused to leave the hospital. She eventually conceded to having the procedure, when her counsel was unavailable for calls. The c-section was successful; ironically, by some miracle, her baby was born healthy and with no further complications.

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That scenario may seem outlandish, but it is quite common in both rural and urban areas globally. Many women are still under the impression that caesarean deliveries or c-sections are unacceptable, due to deeply-rooted cultural myths, traditions, religious beliefs, and social pressure. C-sections are disparaged and described as “modern day”, “lazy”, and “unnatural”, often in a derogatory manner, while equating it to the negative effects of modern-day advancements in technology.

These assumptions are false, as caesarean sections have been a part of ancient western and non-western cultures. They have been described in greek mythology, ancient chinese etchings and even in the earliest accounts of African living. In 1879, the procedure was observed in Uganda by a British traveller, R.W. Felkin (with similar reports in Rwanda). He described African women who used banana wine for sterilisation, anaesthesia and pain relief on the patient’s abdomen prior to surgery. They even made a midline incision and used heat to prevent bleeding. Please note that this account is only the first available historical documentation of the procedure in Africa- there is no available information on how far back the origins of this practice goes. This eliminates the claim of modernity for c-sections.

It is also immensely inaccurate to describe a c-section procedure as lazy, and this can be rebutted in two fold. Firstly, a c-section requires multiple, well-trained and expert personnel: an obstetrician, anesthesiologist, perioperative and neonatal nurses (circulator, scrub/instrument nurse, first assistant), surgical technicians, surgical aide, etc. And secondly, whether medical or elective, the procedure has both physical and psychological consequences on the mother. The post-op or post-delivery hospital stay could be up to three to four days (or longer if there are complications), and the post-op wounds could take up to six weeks to fully heal. As with any major surgical procedure, there are risks of infection, bleeding, blot clots, etc. However, it is important to weigh the risks against the benefits of the procedure.

Which leads to the claim that it is ‘unnatural’. 85% of caesarean deliveries occur as a result of breech presentation, dystocia, and fetal distress, and would therefore be deemed essential to keep the fetus alive. There are also several maternal indications for cesarean delivery such as repeat cesarean delivery, fibroids in the lower part of the uterus, obstructive lesions in the lower genital tract, pelvic abnormalities that could interfere with descent of the fetus during labour, certain cardiac conditions, etc. It is important to note that vaginal deliveries also have many perinatal and postnatal consequences; sometimes a c-section could be the determining factor between life or death for both mother and child.

The global average CS rate is rising at an average rate of 4.4 % per year (1990 to 2014) due to more women opting for elective c-sections. However the lowest rates are found in Africa (7.3 %), followed by Asia (19.2 %), Europe (25 %), Oceania (31.1 %), and North America (32.3 %), with Latin America and the Caribbean having the highest rates at 40.5 %.

According to the WHO, about 34% of global maternal deaths occur in Nigeria and India alone.
The maternal mortality of Nigeria is 814 (per 100,000 live births), and this has been attributed to a complex matrix of socio-economic issues. With such figures, the focus should be on the safe delivery of a healthy child, and preservation of the quality of life of the mother.

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