A few months ago, Nigeria had a maternal mortality awareness week. Mrs Momah Phillipa, Director, Family Health, Federal Ministry of Health, said Nigeria started commenorating Safe Motherhood Day in 1998, adding that in view of the current focus on integration of service along the continuum of care, Nigeria celebrated the Maternal, Newborn and Child Health week in 2010 with a rally and symposium to promote cost effective intervention in reducing maternal mortality. She also said that the NDHS 2008 Maternal Mortality in Nigeria was 545 per 100,000 live births.

Disparity in the rate between rural and urban areas

Dr. Aisha F. Siddiqi-Hussain of the Peace Care Clinic, Abuja, is a Reproductive Health Specialist who believes that the maternal mortality rate is much lower in the cities than in the rural areas. However pointed out that. It  was quite multifactorial. E.g. access to healthcare services, middle and high socio-economic status, higher level of awareness, early recognition/diagnosis of problem in ante natal care, appropriate  treatments and delivery options and Caesarean Section(CS) when necessary.

On the issue that some elite wives have the option of Caesarean Section in the cities, which minimizes their risk of maternal mortality, Dr S. O. Onuh, the Medical Director of the Nisa Premier Hospital, Abuja, also a gynecologist, said, “Choice of CS or no choice of CS is not the ultimate when we talk of maternal mortality. When we are looking at Caesarean Section, we discover that in the rural areas where there are no facilities or where people have wrong notion about Caesarean Section, a lot of people are left unattended to and it ends up with prolonged labour, obstructed labour and some other complications associated with it and eventually, death might come in. That, in a way will affect the rate of maternal mortality being higher in the rural area than in an urban area.”

He said Caesarean Section should not be looked at alone as a factor, because even in the rural areas where there is proper enlightenment and a good referral system, the issue is that once labour is being prolonged, the patient needs to be moved from where she is obtaining care in the rural area to the urban centre where there are facilities. This, he added would be a way of getting around the paucity of facilities in the rural areas.

Why there is rise in Caesarean Section

There used to be a time when Caesarean Section was rare, that  for one to be told that one has to undergo it created panic in one and one’s relatives. But it is a different story now because of its frequency people have become used to the idea, that it hardly causes a flutter. This makes people believe that hospitals, especially private ones, are pushing for the Caesarean Section just to make money, not necessarily on health grounds.

Dr S. O. Onuh said Caesarean Section is something that is reserved to be done when it is indicated, “To hear that hospitals would want to encourage Caesarean Sections because of  financial benefits is not actually correct on a general not,” he disagreed.

However, he added that he could not deny for other practitioners, where it is being perpetrated by non specialists, saying just because you are a doctor does not mean you are a specialist in a certain area, as there are areas of specialisations. “And the area of Caesarean Section will concern the obstetrician and gynecologist, even though medical staff are trained to do the CS because it can be life saving, doing CS is not the problem. But the decision to do the CS is where the matter lies. Having the acumen to take a decision when CS is necessary,” he explained.

According to Dr Onuh, even though the frequency of Caesarean Section might be abused sometimes, however, the summary is that it is better to do CS in error, that is you offer CS to somebody who actually wouldn’t have needed it than not to offer it to  somebody who needs it and complications would come.

“What I mean is this: If a patient is in labour and there is no doubt as to whether a CS is needed or not or even if it is not labour and the pregnancy has some complications that there is doubt as to whether CS is needed or, sometime, it is better to err on the side of caution than not. It is better to offer CS than to assume that all is well and you allow labour to continue and the baby dies,” he said.

He also said he got complaints on the rise of CS, and not just from private hospitals, but even in government hospitals, the CS rate is actually increasing, compared to what it was before. “This is because enlightenment is increasing and we on the medical side are also being cautious because of the legal implications. You wouldn’t want anything to go wrong and to be dragged to court, so if there is an indication, you don’t want to manage, you want to just go ahead and have a safe mother and a safe baby. But putting cost first is not particularly correct, because if you go to the National Hospital, people are still complaining that CS rate is high, the doctor in the National Hospital is not interested in what material gains he is going to get for doing CS, because at the end of the day, he gets his salary, whether he does CS or not. But the welfare of the patient and the unborn baby is paramount. That is why it seems apparent that CS rate is going up now,” he said.

Dr Siddiq concurred that many practitioners only advice on CS when absolutely indicated and/or vaginal delivery fails or is impossible, “However, there are always those who tend to advice CS because it fetches more money even when not indicated or for social reasons,” she noted.

On why if you have a CS there is the tendency to have it again in subsequent births, Dr Onuh said, “the reason is that once you have a CS at one time you could be allowed to try to deliver by yourself. However, the chance that you will be able to deliver on your own is 70 percent after a previous CS. Seven out of every ten women who have had a CS before achieve vaginal delivery, the remaining three will have a repeat CS.”

He explained that this is so because the womb is already having a scar through the CS, therefore  the chance that the womb will burst in labour is higher than if there were no scar at all before. That is why there is that caution.

He advised, “but when you have two CS following themselves, it is wise not to allow labour because  the chance of rapture of the womb which will lead to either the mother or baby’s death is high. So we now advise that if you have a CS twice before, it is better to continue to have the caesarean, and with modern facilities now, there is no limit to the number of CS you can have. You can have six babies through CS.”

He however hastened to add that, it has to be managed in a modern facility, and not just by staying in a village or staying without a specialist attention, “Before, after four cesareans, that is the end, you tie the tubes, but I have delivered someone five times through CS, but caution is what we are talking about. It has to be done cautiously.”

Problems with CS, according to Dr Siddiqi, include longer healing time, more discomfort or pains afterwards, wound infection, breastfeeding problems if under anesthesia and unable to breastfeed immediately and complications of anesthesia.

Role of government and NGOs in combating maternal mortality in Nigeria

Mrs Momah Phillipa, Director, Family Health, Federal Ministry of Health, said nongovernmental organisations are complimenting the efforts of the federal government to achieve a reduction in maternal mortality.

Efforts made by the government to address maternal mortality reduction, she said, are: community mobilisation, collaborating with NGOs and development partners on reproductive health activities, introduction of Midwives Services Scheme whereby newly graduated midwives as well as unemployed and retired midwives are recruited and deployed to rural areas.

Also, there are: introduction of midwifery kits and mama kit for clean and safe delivery, introduction of Basic Midwifery with one year mandatory rural posting after graduation, use of magnesium sulphate and misoprosaol for the management of Eclampsia and Post Partum Haemorrhage among others.

The activities of some NGOs are looked at with suspicion, with skeptics saying some are actually involved with maternal mortality just to make money, or are they achieving a positive impact? Dr  Ejike Oji, Country Director, IPAS said, “People always do things for different reasons, but I always say that out of self interest occasional common good can come out. If some NGOs are doing it to get money, we will not say that the work they are doing is not actually impacting. If you look at the reduction in maternal mortality that means the strategies employed have yielded some results. At least for us in IPAS, we have done a lot of work in 19 states. In just Kano State alone, from our records, we have treated over 68,000 women in our programmes in the past seven years. Other NGOs helped in their own ways to save women’s lives. So, it is actually having a positive impact. There are some level of improvement; the govt. is also becoming more responsible by deploying resources.”

However, Hajiya Halima Ben Omar, Director, Women in Media, Kano State, who is involved in maternal mortality said the NGOs that are doing well or achieving a lot are those that collaborate with the government and work directly with the people. She added that some NGOs are just ‘laptop bag’ ones without an office, depending on your connection in the donor circle.

Are those that have Caesarean Section lesser women?

Many people believe that another way for a woman to prove her ‘womanhood’ apart from conceiving is to have a natural birth, and therefore those who go through  CS and never experienced natural birth are looked upon as having ‘missed’ the real experience of being a  woman. Some are even taunted or mocked with having, ‘a man’s waist.’

Hajiya  Ummi Habib, who had three CS said, “I feel a little sad. If I had a choice, I would have opted for natural birth because natural delivery is much less painful, as I heard from women who ‘enjoy’ that. I had to give birth to my first child through CS because the placenta tried to come out before the baby.”

According to her, even though she didn’t feel inadequate or less than a woman, because she had conceived after all, she still missed giving birth naturally, “because I learned that after the painful labour and delivery, the woman feels completely at peace.”

But for Hajiya Binta Ibrahim, she feels inadequate for not having a natural birth. “I have four children through CS and I am the eldest in my house. You can imagine how I feel when all my younger sisters have natural births. And If they and my friends are discussing the wonders of it, the relief after the labour pains, I feel somehow,” she said.

According to Dr Siddiqi, in general, in Africa, it’s important for a woman to be able to give birth vaginally, that even with high level of literacy, the trend is always towards natural birth and women are passionate about it. “But when it comes to an emergency like fetal distress during labour, they do not hesitate to give their consent for a CS to save the life of their baby,” she added.

Dr Onuh said they are trying to disabuse the minds of people because there are some cultural beliefs that if you have not laboured, not just labored, but if you have not delivered naturally, “you have not arrived, you are not a woman enough, because it is not correct.”

He argued that at the beginning of nature, there were no cars and asked why we are not walking on our legs, why we are not riding camels, why we are travelling by air. “Is it not natural to be travelling by road, is it natural to be travelling by air? So this is what we should consider. God made man and gives man the knowledge to help nature, to help humanity if one is applying the sciences to alleviate the sufferings of women who because of one reason or another, will jeopardize their lives or the health of their babies.”

Dr Onuh also explained that having a CS does not necessarily mean that a woman has a problem with her waist or pelvis. “There are many reasons why CS is done. It could be because the woman has a small pelvis, but it could be because of bigger reasons on the baby’s side. When the baby is suffocating, even when the pelvis is as wide as a room, you will not want to wait for that process to be completed, if not the baby will die. So, people having CS are not different from other women, after all, they conceived, they carried the baby for the same duration and they give  birth to the same type of  baby other women are carrying,” he said.

An option for alleviating labour painS

There are so many things surrounding labour, noted Dr Onuh, saying that labour pains could be excruciating sometimes, and it could be tolerable sometimes depending on one’s perception of pain. However, science has also made labour to be easy, as one could go through labour now without a pinch of pain and it’s the process of using epidural, a pain relief in labour.

“It is called epidural anesthesia and you could go through the entire hours of labour which could be two, three or 10 hours without knowing you are in labour and eventually everything comes out fine. Before now, there is  an injection to relieve labour pains but that does not eliminate the pains completely, but the epidural eliminates pains completely, and you go through it without knowing you are in labour, smiling and laughing, enjoying yourself,” he said.

Dr Siddiqi said she advocated  a pain free labour and gives her patients all the options both in Ante Natal Care classes and also during labour to request for pain relief rather than bear the pains unnecessarily.“I am against having them suffer when it comes to be unbearable. They only become distraught and it often affects the progress of labour .As for epidural, it is a very good method of pain relief but you need a very experienced anesthetist for the procedure which can be easily arranged for the patient at only a slightly higher fees,” she stated.