Dear Daktari,
For the two months of June and July 2020, the rates of emergency caesareans for mothers is hovering around 40% (mothers who are admitted in labour or for induction). This, sub-optimally, is an average figure for the private practice rates in Nairobi. As recognised world over, private practice caesarean rates are virtually way above those in the public sector. Some studies quote that the chances of having a vaginal birth were 20% lower in private facilities than public hospitals, and only 15% of first-time mothers had no birth interventions (i.e. induction, episiotomy, caesarean) in private hospitals (these are data from well-organised healthcare systems). For unregulated health systems such as in Kenya, I suspect that the figures would be worse (financial and time advantage for the practitioner). Interestingly enough, a local daily reported that one of the reasons for the increase in caesarean section rates was due to the increase in the number of professionals having babies (quoting a study at the Moi Teaching and Referral Hospital, Eldoret)!
The rates of cesarean sections matter for the mother due to the following reasons: – WHO states that an elective caesarean with no medical indication increases the risk of short-term adverse outcomes for mothers – There is an increased incidence of stillbirths in women who have a scarred uterus from a previous caesarean – Babies born via caesarean are more likely to be admitted to a neonatal unit with breathing difficulties – The primary reason for undertaking a caesarean is a previous caesarean – 80% of women have a repeat, resulting in an ongoing increase in rates. The rates would be higher in our setting, seeing as not all practitioners or facilities provide adequate services/monitoring during labour after a caesarean. As a department, we now do provide services for VBAC (Vaginal Birth After Caesarean) since the latter part of last year. The other reason this figure (80%) may have increased is the reducing size of families due to the socio-economic climate. If you’re going to have only one more baby after the caesarean section for the first one, you may as well have a caesarean again as it is not as risky as multiple repeat caesareans. This is the current thinking of many providers and clients as well, leading to increased numbers of repeat caesarean sections overall. – It is easier to take care of a child after a vaginal birth than it is after a 12cm incision in the lower part of the abdomen. – There may be an increase in the likelihood of the baby developing chronic immune disorders later in life. – Delays in skin-to-skin and bonding may delay satisfactory breastfeeding.
For these reasons, amongst many others, we are in the process of classifying all caesareans done at MPShah using the Robson Classification as recommended by WHO. This will take into account 10 classes of mothers and the reasons why the operation is being done, taking into account the numbers of previous pregnancies, previous caesareans, the way in which the baby is presenting itself inside the uterus, whether the pregnancy has reached term (37 weeks) or not, and whether labour was induced or spontaneous. Auditing the actual reasons helps us to identify outliers and reasons why, and may guide us as to how best to reduce unnecessary interventions that may impact the new family more than we think or know. As a department, we are using the NICE guidelines (CG 190) to help navigate the labour and delivery process, and are aiming to have a setup that is between a birthing unit and an obstetric unit (low-risk labours seem to be more successful in birthing units as opposed to hospital-based units with obstetricians according to the Birthplace Study), so as to reduce the seemingly negative effects of delivering babies in a hospital.
‘ Part of the challenge may be a feature of the species. Homo sapiens have always required some form of extra help being born. Narrow pelvises are required for walking upright, and large frontal lobes are required for nuanced thought. Neither works in our favour when it comes to navigating the birth canal. The unresolved question is how much help is truly necessary – and how much help is too much.’ Dr Neel Shah
Warm wishes, Raj H. Dodia
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References:
https://www.bmj.com/content/343/bmj.d7400 – the Birthplace Study, UK
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