At 15 weeks of pregnancy, 26-year-old Catherine Umija went for an ultrasound to find out the sex of her baby.
The revelation on that day was not just the sex but how many babies she was expecting. She would be a mother of twins – a boy and a girl.
After hearing the news, Catherine decided to go for a caesarean section (CS). “There is no way I was going to deliver naturally,” recalls the Athi River resident. “I went for an elective surgery.” “I did not think I had the energy to push two babies. That would be too much,” she explains.
At 35 weeks, just a week shy to a full-term pregnancy, she experienced false labour. “I was cramping for two days non-stop. The pain was piercing; I would not wish it on anyone. I knew that I was ready to deliver even though it was still earlier than my due date,” she says.
With that glaring signal, she went to hospital for her planned CS. “I stayed in hospital for about two days and the trauma from just the noise of the women in labour put me off. My doctor said my babies and I were not in any danger. The pain had subsided, so I was discharged,” she says.
In the wee hours of August 28, 2018 she went into labour. “At the time, I was living with my mother in Ugenya. I told her how I was feeling and she asked me to be patient and wait for morning,” she recalls.
At 6am on that day, she was taken to a private hospital in the area. It was an hour’s journey to St Mary’s Hospital in Mumias. Upon arrival, the doctors assessed her and immediately she was admitted for an emergency CS.
“The doctor said one of my babies was not breathing properly and it had to be an emergency CS,” she says. “I did not have the luxury to wait despite having in mind that I wanted an elective CS. I was still happy I did not have to push,” she adds.
Three years post-delivery she says she is not ready to experience the pain that comes with a CS wound again. “I will still go for C-section because I am not sure of the other route. But now that I know better, if given a choice, I would vouch for natural birth,” she says.
Ivy Aseka, 24, had not planned on how she would bring forth her son, whom she calls ‘sonshine’. A paradoxical moment came hours before the boy that sparked her life with inexplicable love came out of her.
Hers was an emergency caused by an infection that reduced foetal movements. Her baby’s rhythm and movements had reduced. Her gynaecologist endorsed her admission and contacted a doctor on duty at St Elizabeth Mission Hospital Mukumu.
“The doctor on duty made the C-section call after examination. Induction or a normal delivery was decided to be risky as the baby, whose movements had reduced, would have been in more distress. I was wheeled to theatre at 10pm, prepped, and by 10.35pm I was a mother,” says the mother from Lurambi, Kakamega.
In an emergency situation, there is no room for deliberation. You can either live or die. “At around 8pm on that day just after the decision was made, my family called me, reassured me and those who were present stayed with me,” says Ivy.
His ‘sonshine’ may have come but the experience of bringing him forth was not an easy one, at least via CS. “I was traumatised from the catheter experience to the entire process. Emotionally, I was scared that I would be too weak to take care of my baby. That did happen, but I had help, thankfully,” she says.
The traumatic experience is long gone. But the scar lives on. “Vain as it may sound, I could wear a bikini in a few months and no one could tell. There is some back pain but it is becoming manageable. I am taking it easy and not trying to be superman,” she says.
Ivy says if she were to give birth again, she would opt for an elective C-section. “Although mine was an emergency, I still would not want a vaginal birth. This is because with a C-section, I know what to expect. There is the fear of the unknown with vaginal birth. Once the unexpected aspect of the emergency C-section is removed, I would do CS again in 10 or more years, of course.”
One in five Kenyan women give birth through CS. Having saved mothers and babies’ lives, it is doubtlessly a safe alternative to vaginal birth in case of an emergency.
Cross the red line
Data released by the Health ministry earlier this year indicates a spike in CS cases compared to previous years. The survey shows the number of women opting for C-section surpassed the country’s target by 0.4 per cent.
Kenya crossing the red line raises concerns about CSs. Are more women embracing elective C-section or are they forced to by circumstances?
Specialists now say there is more than meets the eye in the numbers.
Before the introduction of CS to the world, the fate of the mother and the baby was unknown. Medicine was still evolving and the use of anaesthesia, antibiotics, blood transfusion and even neonatal care, were nonexistent.
With technology shaping up, many women now opt for painless delivery and elective CS has become popular.
Dr Jonathan Mashala, a specialist in obstetrics and gynaecology, says CS is mostly done due to obstetric indication. In some cases, however, it is done on demand.
Usually, there is a standard used by doctors to access whether a patient needs C-section or not – Robson classification. This categorises women based on factors such as previous CS, gestational age and onset of labour.
Dr Mashala says there are a number of risk factors that can make one undergo CS. Two of the issues are those faced by Catherine and Ivy – twins and infection at birth, respectively.
Other factors include: breech presentation at term, primary genital herpes, pelvis retraction, non-reassuring foetal status and transmissible diseases.
But, he says there is not much difference between a baby born via CS and one born naturally save for their lung maturity. “If the baby is born via CS, it will not benefit from the maturation of the lungs due to lack of cortisol (due to stress during labour). This is released during natural delivery but not via CS,” he explains.
He advises against CS when there is no emergency because complications may arise after CS deliveries. There could be excessive bleeding, injury to other organs, rupture of the uterus in subsequent pregnancy, an abdominal infection or an infection in the surgical wound, or paralytic ileus (blockage of the intestines).
For Caren Cheruto, 25, a bad experience lead to her decision to opt for CS. “I laboured from around midnight to 3pm the following day. My pelvic bones could not open, but the baby was almost coming out, and so he had to forcibly do so,” she says of her experience in a Nakuru hospital.
Before then, a nurse had noticed she needed an emergency C-section because of the nature of her pelvic bones. “I was to be taken to theatre but someone else was in. The baby’s head was already showing. I had to give birth naturally, leading to complications thereafter,” Caren explains.
Sign a consent
It took her about four months to fully heal. “I struggled to sit for three months and I was always on painkiller,” she says.
She is now expecting her second baby and the pain in the pelvic area is back but mild. “When I went to hospital during my first trimester, I told the doctor I would go for an elective CS and he agreed,” she says.
With just a few months before she gives birth, she knows she has a date with Galaxy Hospital in Isiolo where she will give birth via elective C-section.
Dr Simon Kigondu, an obstetrician/gynaecologist, says a woman should be properly informed about an elective CS before choosing this route. “As gynaecologists, we plan for elective C-Sections. If the mother goes into early labour, it can be done as an emergency CS,” he explains.
He adds: “Women should be told about the benefits and risks of both vaginal and caesarean deliveries during antenatal clinics. The ideal is to have an uneventful normal delivery,” adds Dr Kigondu.
For an elective C-section, a doctor should inform the patient about the complications before, during and after operation. “After understanding the details, a woman signs a consent,” he says.
“The risks of a CS are higher than those of natural birth because they include greater blood loss, risk of greater infection and risk of injury to internal organs, higher risk of thrombosis and an additional risk of anaesthesia,” he says.
Kenya’s average CS rate currently stands at 15.4 per cent, and data from the Health ministry points out that counties in urban areas and the Central region have the highest number of cases.
“For CS, we normally look at two thresholds. If it less than 10 per cent, it means there is a limited access when needed. It means we could be losing mothers who need it as a result of emergencies that’s why the target is 15 per cent. Beyond 15 per cent is seen as misuse,” explains Dr Helen Kiarie, Head of the Division of Health Sector Monitoring and Evaluation at the ministry.
Kirinyaga County, which has about 31 per cent of cases, has the highest number of CS deliveries, according to the report. It is followed closely by Kiambu, Nairobi, Tharaka Nithi and Embu all with above 25 per cent of cases.
Dr Kiarie links the high numbers to more women embracing hospital births. But, her puzzle is whether all pregnancies via C-section have been informed by emergencies. “In Nyeri, for instance, private facilities have high rates of CSs compared to government facilities,” she says.
On the flip side, counties in the Northern, Western and Nyanza areas have a relatively lower rate of below 10 per cent. The lowest number of CSs were done in Mandera at 2.2 per cent.
Dr Kiarie says the low number of cases could be a result of two factors: women in those regions could be giving birth at home or they are yet to embrace C-section.
“Counties with high CS rates are economically well off. Is it that people want to make more money out of CSs?” poses Dr Kiarie.
Insurance companies have also noticed an increase in the number of CSs. An insurance manager, who did not want to be named as she is not authorised to speak to the press, says some hospitals are using C-sections “to meet financial targets”.
“The hospitals prefer clients to go through the CSs majorly because private hospitals are in business and some of them give doctors targets. That way, doctors end up recommending clients for CS,” she says.
In private hospitals, for instance, CS deliveries range between Sh130,000 and Sh300,000 while normal birth is about Sh75,000 to Sh150,000.
“Unfortunately, we do not have a unified way as insurance companies to try and ‘bulldoze’ hospitals to minimise the costs. We negotiate separately, giving the hospitals an upper hand,” she says. “At the end of the day, the choice is the clients,” she adds.
Globally, Brazil and China have the highest CS rates, with an average of about 50 per cent.
A Lancet study shows the global increase in C-section births from 2000 to 2015 was as a result of an increase in hospital births. The study shows there has been a 66.5 per cent increase of hospital births and 33.5 per cent are skewed to C-section.
“Optimisation of CS use is needed, underpinned by a better understanding of demand and supply factors that drive the overuse of CS and by greater efforts to ensure universal access to CS for all women,” says the study.