C-section deliveries in Uganda; Why you should get concerned

By, Asiimwe Godfrey (asiimweg1@gmail.com)

C- SECTION DELIVERIES IN UGANDA; WHY YOU SHOULD GET CONCERNED

OVERVIEW

Cesarean delivery (C-section) is a surgical procedure used to deliver a baby through incisions in the abdomen and uterus.

The World Health Organization (WHO) suggests that a caesarean delivery rate of 15% of all births should be taken as a threshold that should not be exceeded rather than a target to be achieved (WHO, 2009). WHO statement further states that medical practitioners should not undertake cesarean sections purely to meet a given target or rate, but rather should focus on the needs of patients.

However studies show that in High income countries and other middle income countries, C-section is being provided at higher rate above what is recommended and in most cases when there is no medical or obstetric indication (Thomas J & Paranjothy, 2001). For example Cesarean birth rates continue to upsurge globally with recent (2016) reported rates of 24.5% in Western Europe, 32% in North America, and 41% in South America. In Africa it stands at a rate of 7.3 % (Betran AP et al., 2016).

Medically, C-section can be recommended  in case of breech birth where a baby is born bottom first instead of head first, as is normal, when there is obstructed or prolonged labor, when there is problems with the placenta, when a mother is carrying multiples, Prolapsed umbilical cord, if a mother had a previous C-section, high blood pressure of the mother and intrapartum fetal distress among other reasons (WHO, 2009). In such situations C-section is considered essential in averting major obstetric complications that lead to maternal and neonatal, morbidity and sometimes mortality (Gibbons L, et al., 2010).

State of Health care in Uganda

Uganda’s healthcare system encompasses multiple levels of care, including health centers II, III, and IV, general hospitals, and finally referral hospitals.

According to Uganda Ministry of Health, (2020) there is a total of 155 hospitals in Uganda both Public and private. Of these 2 (Mulago and Butabika) are National referral hospitals while others are regional referral and General hospitals. 65 are government owned, 63 private not for profit (PNFP) and 27 private. As of 2014/15 financial year, a total of 36% of all deliveries were produced by hospitals.

For services related to childbirth, health center IIs and small clinics are required to provide crucial obstetric care services such as antenatal care, preventive services, and treatment of common illnesses.

Health center IIIs on the other hand provide a broader range of services, such as normal deliveries and first aid for complications related to pregnancy, labor, and delivery, assisted vaginal delivery, manual removal of placenta, and removal of retained products for women with pregnancy-related complications. All 139 General hospitals in Uganda provide maternity, emergency surgeries and blood transfusion services among others (Ministry of Health, 2020).

Health center IVs are the first referral level for low or moderate-risk pregnant women. Both health center IVs and hospitals are mandated to provide comprehensive emergency obstetric care, including cesarean section and blood transfusion services as well as the lifesaving interventions provided at lower health centers (Wilunda C, et al., 2015).

State of C-section deliveries in Uganda

As already discussed above, a C-section can be planned ahead of time especially if a woman develops complications while pregnant or had a previous C-section and aren’t considering a vaginal birth. In Uganda according to recent statistics from Uganda Demographic and Health Survey (UDHS, 2016), 7% of all live births are C-section deliveries. Most C-section deliveries have been reported in Kampala at 14%. C-section deliveries stand at 13% in urban residences of Uganda as compared to 5% in rural residences and 16% of the richest use C-section deliveries in relation to 3% of the poorest (UBOS 2016).

Concerning timing on decision to go for C- section according to UBOS, (2016), 33% of women decided to go for C-section before labor started as compared to 67% who decided to go for C-section after labor had started. Among those in urban residences, 40% decided to go for labor before labor begun compared to 29% of women in rural residences. 45% of the richest decided to go for C-section before labor begun compared to 20% of women who belonged to poorest category. Among those with higher education, timing of the decision to go for C-section stood at 47% compared to only 19% of those without formal education.

Different reasons inform why there is high demand for planned C-section deliveries in Uganda especially among the educated, urban and rich populations. In most cases some women request C-sections with their first babies mainly to evade labor and associated complications of vaginal birth such as perineal laceration (Vaginal tear). Others because they want to take advantage of the convenience of a planned delivery. This is however; highly discouraged since women who have multiple C-sections are at increased risk of placental problems as well as heavy bleeding, which might require surgical removal of the uterus.

Why you should get concerned

C-sections deliveries can cause significant complications including disability or death, especially in settings that lack the facilities to conduct safe surgeries or treat impending complications because of their increased cost.

A study by Keag OE, et al., (2018) to establish Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies, the authors reveal that “while pregnant women are usually well-advised of the short-term outcomes of having a cesarean, they are less informed about the long-term impact of a C-section – not only on their health and that of their baby, but also on their ability to carry future pregnancies”.

It is also revealed in this study that children delivered by cesarean were 21% more likely to develop asthma within the first 12 years, and 59% more likely to become obese by the age of 5.

The study further reveals that, the risk of placenta previa (a condition when a baby’s placenta partially or totally covers the mother’s cervix), was 74 percent higher for mothers who had a C-section and the risk was even higher for placental abruption. When compared with women with previous vaginal delivery, women with previous cesarean delivery had increased odds of miscarriage.

Furthermore, C-section deliveries should concern all of us mainly because of the following risks associated associated with it;

  1. Breathing problems. A study by British medical journal (2007) shows that Babies born by planned C-section are more likely to develop transient tachypnea  which is a condition of breathing disorder seen shortly after delivery in early term or late preterm babies
  2. Postpartum hemorrhage which is heavy bleeding during and after delivery.
  3. Surgical injury. Sometimes accidents can happen on the baby’s akin during surgery.
  4. Infections such as endometritis which is the infection of the lining of the uterus. This too might occur due to C-section.
  5. Blood clots. High risks of developing a blood clot inside a deep vein can occur as a result of C-section deliveries, especially in the legs or pelvic organs and if a blood clot reaches the lungs and blocks blood flow, the outcome can be life-threatening.
  6. Increased risks during future pregnancies. After a C-section, a woman might face a higher risk of potentially serious complications in a subsequent pregnancy than she would after a vaginal delivery meanly because of placenta previa and uterine rapture of which all these conditions block a woman from getting pregnant again.

Conclusion

The writer recommends that much as C-section can be a life-saving intervention when medically indicated, this procedure can also lead to short-term and long-term health effects for women and their babies.

Planned deliveries seem to be safer than emergency caesarean section ones, when medically indicated; but in case they are not medically recommended, they should be highly discouraged due to major risks involved as discussed earlier. This can be done in many ways mainly at a health facility setting.

On the other hand however, Emergency obstetric services of which emergency C-section deliveries is part of, should be extended to all populations in Uganda especially the rural places that are hard to reach so that life of the mother and the fetus is saved. It should be noted that in Uganda majority (67%) of pregnant women decide to go for C-section after labor pains have begun (UBOS, 2016). This is deadly because there might be no room for preparation like incase blood transfusion is needed.

Further qualitative research studies can be done especially among women of certain class like the rich, highly educated to find out their views informing their high desire for planned deliveries even when not medically recommended.

Appreciation

My sincere gratitude goes to all the mothers in Uganda; you pass through a lot to give life.

REFERENCES

  1. Betran AP, Torloni MR, Zhang JJ, G.lmezoglu AM for the WHO Working Group on Caesarean Section. WHO Statement on Caesarean Section Rates. BJOG. 2016;
  2. Betran AP, Ye J, Moller AB, Zhang J, Gulmezoglu AM, Torloni MR. The increasing trend in caesarean section rates: Global, regional and national estimates: 1990–2014. PLoS ONE. 2016;11(2):e0148343. pmid:26849801
  3. Betran AP, Ye J, Moller AB, Zhang J, Gumezoglu AM, Torloni MR. The increasing trend in cesarean section rates: Global, regional, and national estimates: 1990–2014. PLoS One. 2016;
  4. Gibbons L, Belizan JM, Lauer JA, Betra AP, Merialdi M, Althabe F. The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed per Year: Overuse as a Barrier to Universal Coverage. World Health Report (2010).
  5. Keag OE, Norman JE, Stock SJ (2018) Long-term risks and benefits associated with cesarean delivery for mother, baby, and subsequent pregnancies: Systematic review and meta-analysis. PLoS Med. https://doi.org/10.1371/journal.pmed.1002494
  6. Monitoring Emergency Obstetric Care: A Handbook. World Health Organization, 2009. Geneva, Switzerland.
  7. Thomas J, Paranjothy S. Royal College of Obstetricians and Gynaecologists Clinical Effectiveness Support Unit. National Sentinel Caesarean Section Audit Report. RCOG Press; 2001.
  8. UBOS & ICF. (2016). Uganda Demographic and Health Survey, (March), https://doi.org/10.2307/41329750
  9. Wilunda C, Oyerinde K, Putoto G, Lochoro P, Dall’Oglio G, Manenti F, Segafredo G, Atzori A, Criel B, Panza A, et al. Availability, utilisation and quality of maternal and neonatal health care services in Karamoja region, Uganda: a health facility-based survey. Reprod Health. 2015;