INTRODUCTION

A Caesarean section is a surgical procedure that involves the birth of a baby through an incision in the abdomen and uterus (Ugwu, Obioha, Okezie, & Ugwu, 2011). This is a life-saving obstetric operation that may be required (and often the only viable choice) in high-risk pregnancies such as those with multiple or large fetuses, breech presentations, obstructed labor, and in women with HIV/AIDS (Lujiao Huang, 2021). Cesarean birth is a major operation with a greater risk of complications just like any other major surgery (Healthline, 2016). 

According to the World Health Organization (WHO), a country’s Caesarean rate should not be less than 5% and fall within a threshold of 10 – 15% in order to successfully minimize maternal deaths. In Nigeria, the incidence of caesarean section (CS) ranges from 2-2.7%, and it would have been greater if the taboo surrounding caesarean surgery and other forms of breech presentations were not widely believed (Udobang, 2018). These would be properly discussed in subsequent sections of the article. For the seven-year period preceding the study, Nigeria’s maternal mortality ratio (MMR) was 512 deaths per 100,000 live births, and this could be as a result of the country’s very low CS rates. The 2018 MMR confidence interval runs from 447 to 578 deaths per 100,000 live births  (NDHS, 2018). 

CAESAREAN SECTION STATISTICS

According to recent WHO figures, the global rate of C-sections has increased from around 7% in 1990 to 21% in 2019, and is likely to rise further over the next decade (Betran, Ye, Moller, Souza, & Zhang, 2021).

Figure 1, Trends (1990–2018) and projections (2030) in global, regional and subregional estimates of CS rates. Source: (Lujiao Huang, 2021)

If current patterns of growing Caesarean Section rates continue, the research indicates that the proportion of CS deliveries in various regions will be as follows by 2030: Eastern Asia (63%), Latin America and the Caribbean (54%), Western Asia (50%), Northern Africa (48%), Southern Europe (47%), Australia and New Zealand (47%). CS should be the last resort to a pregnant woman’s inability to deliver through natural means and not advisable for any other reason. 

Figure 2, Percentage of live births delivered by cesarean section worldwide in 2000 and 2015, by region source: (Statista 2021)

In figure 2, we can see that West and Central Africa had the lowest rate of caesarean section at 3% and 4.1% in 2010 and 2015 respectively, which is way below the 10% threshold recommended by the WHO. The rate of caesarean sections have increased over the years and this can be attributed to a number of factors and will be discussed in subsequent sections of this article.

zonePercentage delivered by caesarean sectionBefore onset of labor painsAfter onset of labor painsNumber of births
North Central 2.71.21.54,619
North East0.90.20.76,213
North West0.70.30.412,558
South East5.82.92.93,428
South South5.12.132,968
South West7344,407

Table 1, Percentage of deliveries by caesarean section in regions in Nigeria ([Nigeria] & ICF., 2019)

Figure 3, Percentage of live births in the 5 years preceding the survey delivered by caesarean section ([Nigeria] & ICF., 2019)

Figure 4, The states of Nigeria and their MMR categories 2012 (Abimbola, Okoli, Olubajo, Abdullahi, & Pate, 2012)

The CS rate in Nigeria remains low, at 2.7% of births between 2013 to 2018. The North West and North East regions have the highest number of births and the lowest percentage of deliveries by caesarean section as illustrated on table 1 (Berglundh, Benova, Olisaekee, & Hanson, 2021). Rural residence, religious beliefs, and a lack of education in the husband/partner were all substantially related with a lower prevalence and lower probabilities of caesarean birth (Adewuyi, Auta, Khanal, Tapshak, & Zhao, 2019). On the other hand, the highest number of maternal mortality rates are seen in the same regions of the country with low caesarean section rate as shown in figure 4.  

Figure 5, Chart of childbirth based on delivery location (Mallick, Tukur, & Kerry, 2016).  

Majority of deliveries and childbirths in Nigeria occur at homes and not in hospitals where adequate medical interventions can be administered (Mallick, Tukur, & Kerry, 2016). This is also coupled with the fact that a higher percentage of deliveries occur in rural settlements as we would see in figures 8.

Figure 6, Caesarean section rate by region of residence in Nigeria 2013 (Adewuyi, Auta, Khanal, Tapshak, & Zhao, 2019).

Figure 7 Percentage delivered by caesarean section by rural–urban residence in Nigeria 2018 ([Nigeria] & ICF., 2019).

People living in urban areas have more access to caesarean sections, this can be attributed to the number of skilled medical practitioners in these environments and women in rural areas in serious need of this life saving caesarean section operation have little or no access to this medical intervention. 

Figure 8, Distribution of live births in the 5 years preceding the survey by place of delivery 2018 ([Nigeria] & ICF., 2019)

There is twice the number of children delivered in urban areas delivered in rural areas. The rural areas need more access to the C-section and more skilled attendances and also financial support as C-sections are more expensive than Natural births.

Figure 9 Percentage of delivery by C-section based mothers on educational status ([Nigeria] & ICF., 2019)

There is a relationship between C-section and educational qualification of the mother, this can also be reflected in the rate of rural areas C-sections as there are more uneducated women in these environments. 

Figure 10, Mothers worldwide description of Caesarean section. source: (Statista 2021)

Most pregnant women already have previous knowledge or perception about caesarean section and natural birth, these perceptions and understanding of caesarean section is attributed to their educational level. Some pregnant women in developed (and some developing) nations are increasingly choosing caesarean deliveries for a variety of reasons, including the desire to avoid substandard intrapartum care, the desire to eliminate labor pains, and the safety of their infant (Ryding, 1993; Johanson, El-Timini, Rigby, Young & Jones, 2001). A research by Michael Aziken, Lawrence Omo-aghoja & Friday Okonofua in 2007; It was shocking to learn that up to 19 percent of women would still refuse CS, even if it meant risking their lives or the lives of their babies, some women believed that a woman’s inability to have a spontaneous vaginal birth was due to a lack of prayers for heavenly intervention or a previous offense committed by the lady. All these factors play a role in a pregnant woman’s description of caesarean section(Aziken, Omo-aghoja & Okonofua 2007).

Figure 10 presents: These are replies to an online survey on mothers’ experiences with Caesarean sections, with the question “Would you describe your experience as…” (There may be more than one answer) published by Statista 2021. The highest number of women in the research regard their caesarean section experience as being a “Traumatic” experience. As shown in figure 10, a lot of women reported their caesarean section as disappointing since it did not live up to their expectations. Others believed that the caesarean section was the simpler technique with less agony, but were confronted with a different reality (Udobang, 2018). The women who presumed the caesarean section as a simpler and less agonizing procedure were then faced with the post-operative instructions to follow for at least four to six weeks following the surgery. These instructions are designed to help avoid any behaviors that may result in abdominal muscle tension, increased discomfort, or wound dehiscence. Heavy lifting (such as carrying a full laundry basket), raising arms far above one’s head (required to peg clothing on an outside clothes line), driving a car, and participating in sexual intercourse were among the activities women reported being advised to avoid in the near term. However, the women were typically dissatisfied and frustrated with the physical constraints imposed by surgical delivery (Kealy, Small, & Liamputtong, 2010).

MYTHS ABOUT VAGINA DELIVERY (VD), CAESAREAN SECTION (CS) AND EFFECTS 

Traditionally, marriage is a requirement for most Nigerian women, and bearing children is a badge of honor(Udobang, 2018). When you are unable to give birth traditionally (Vagina delivery), it might be interpreted as a reflection on your womanhood, prompting the labels “weak” and “lazy.” Also, the notion that vaginal birth corresponds to maternal virtue, whereas C-sections do not, existed in the past (Udobang, 2018). Christian women frequently hear that giving birth vaginally like a “Hebrew woman” demonstrates courage and competence (Heather, 2019). The situation may be less severe in other nations, such as the United Kingdom and the United States. However, women are still stigmatized for having Caesareans (Roudsari, Zakerihamidi, & Khoei , 2015). On the other hand, in Iran, the mode of delivery may be viewed as a status signal, with regular vaginal delivery regarded as a low-cost way of delivery and caesarean section regarded as a prestigious mode of delivery (Roudsari , Zakerihamidi , & Khoei , 2015).

There is also a misconception that by undergoing a C-section, you can escape the discomfort of labor while also lowering your chance of problems such as vaginal prolapse. A C-section does not cause discomfort during the process, but it is significant abdominal surgery that necessitates a recovery period, recovering from the C-section procedure may be more difficult than recovering from vaginal birth (Kealy, Small, & Liamputtong, 2010).

All these cultural beliefs and traditions about pregnancy and delivery are still prevalent in communities today, particularly in rural areas. It covers many elements of a pregnant woman’s everyday life, from dietary habits through the procedure and manner of delivery (Ahmad, Syed Nor, & Daud, 2019). Stigma is harmful. Women and society in general are not discussing the scandal of so many women dying in delivery sufficiently. Every day, there are several instances ranging from ruptures and postpartum hemorrhage to fatalities (Udobang, 2018).

FACTS ABOUT CAESAREAN SECTION

A research found that maternal complications were more common in women receiving caesarean sections, according to the study. In Brazil, however, it was shown that the probability of postpartum mother death was nearly three times higher with caesarean than with vaginal delivery (Esteves-Pereira , et al., 2016).

A third of all deaths after caesarean section were ascribed to postpartum hemorrhage (32%), 19% to pre-eclampsia, 22% to infection, and 14% to anesthesia-related reasons. This is consistent with a growing body of research warning against caesarean section as a main cause of postpartum hemorrhage, and it highlights resource and skill shortages in managing severe obstetric hemorrhage, and it emphasizes resource and talent deficiencies in the management of acute obstetric hemorrhage.

Previous research indicated that having a C-section was one of the most important indicators of postpartum post-traumatic stress disorder (PTSD) and depression (Wijma, Soderquist, & Wijma, 1997; Soderquist, Wijma, Thorbert, & Wijma, 2009). It has been widely documented in the anesthetic literature that intraoperative consciousness can result in PTSD in a percentage of patients, anaesthesia is always used during a C-section, as a result, rather than the C-section itself, all of the events before or surrounding the C-section are likely to contribute to the development of PTSD or the PTSD profile (Aceto, et al., 2013; Lopez, Habre, Van der Linden, & Iselin-Chaves, 2008; Osterman, Hopper, Heran, Keane, & van der Kolk, 2001).

WHERE WE ARE AND WHERE WE ARE GOING TO 

The average cost of a caesarean section at a public hospital is N68000.0, with a standard deviation of N8101.6. The minimum and maximum costs for a caesarean section are N60,000 and N90,000, respectively. A caesarean section in a private hospital, on the other hand, costs N160, 000 on average, with a standard variation of N19, 720.3. The cheapest and most expensive caesarean birth costs are N120, 000 and N175,000, respectively. The cost of the Caesarean section is twice the price it will cost for a Vagina delivery (Awoyemi, 2020). 

The continued increase in C-section has been attributed to both medical and social causes. Complications during childbirth are the medical reason responsible for caesarean delivery, but socioeconomic considerations such as age, education, household socioeconomic status all affect the probability of a Caesarean section. Also, with the rising acceptance and increasing trend of the caesarean section in developed countries there is surely going to be the same effect in the Nigerian society. 

CONCLUSION AND RECOMMENDATION

There are substantial differences in a woman’s availability to caesarean sections depending on where she lives in the world. In Nigeria, the problem of affordability and access is especially difficult in rural regions, where about 58 percent of births are performed by inexperienced birth attendants, the Government and Non-governmental agencies will need to assist by make this procedure affordable and accessible to rural communities that constitute a large number of the deliveries and maternal mortality. 

References

[Nigeria], N. P., & ICF. (2019). Nigeria Demographic and Health Survey 2018. Abuja, Nigeria, and Rockville, Maryland, USA: NPC and ICF: National Population Commission (NPC).

Abimbola, S., Okoli, U., Olubajo, O., Abdullahi, M., & Pate, M. (2012). The Midwives Service Scheme in Nigeria. PLoS Medicine, e1001211.

AD, I., N, A., & J, Z. (2018). A five-year survey of cesarean delivery at a Nigerian tertiary hospital. Tropical Journal of Obstetrics and Gynaecology, 14.

Adekanle, D., Adeyemi, A., & Fasanu, A. (2013). Caesarean section at a tertiary institution in South-western Nigeria a 6-year audits. Open Journal of Obstetrics and Gynecology, 357-361.

Aceto, P., Perilli, V., Lai, C., Sacco, T., Ancona, P., & Gasperin, L. (2013). Update on post-traumatic stress syndrome after anesthesia. Eur rev med Pharmacol Sci, 1730–7.

Adewuyi, E., Auta, A., Khanal, V., Tapshak, S., & Zhao, Y. (2019). Cesarean delivery in Nigeria: prevalence and associated factors―a population-based cross-sectional study. BMJ Open, e027273.

Ahmad , N., Syed Nor , S., & Daud , F. (2019). Understanding myths in pregnancy and childbirth and the potential adverse consequences: a systematic review. Malays J Med Sci, 17–27.

Berglundh, S., Benova, L., Olisaekee, G. & Hanson, C., 2021. Caesarean section rate in Nigeria between 2013 and 2018 by obstetric risk and socio‐economic status. Tropical Medicine & International Health, 26(7), pp. 775-788.

Betran, A., Ye, J., Moller, A.-B., Souza, J., & Zhang, J. (2021). Trends and projections of caesarean section rates: global and regional estimates. BMJ Global Health, e005671.

Bosede, Olanike, Awoyemi,. (2020) The Rate and Costs of Caesarean Section among Women in Ado-Ekiti, Nigeria. Health Econ Outcome Res. 001-005

Esteves-Pereira , A., Deneux-Tharaux , C., Nakamura-Pereira , M., Saucedo , M., Bouvier-Colle, M.-H., & do Carmo Leal , M. (2016). Caesarean delivery and postpartum maternal mortality: a population population based case control study in Brazil. PloS One.

Healthline. (2016, July 8). Reasons for a C-Section: Medical and Elective. From Healthline: https://www.healthline.com/health/pregnancy/c-section-reasons#Takeaway-

Heather, R., 2019. Why are women declining this surgery?. [Online]
Available at: https://www.bbc.com/future/article/20190612-caesarean-sections-in-africa-stigma-and-maternal-mortality.

Johanson RB, El-Timini S, Rigby C, Young P, Jones P.  2001. Caesarean section by choice could fulfill the inverse care law. Eur J Obstet Gynecol Reprod Biol. 20-2.

Kealy, M. A., Small, R. E. & Liamputtong, P., 2010. Recovery after caesarean birth: a qualitative study of women’s accounts in Victoria, Australia. BMC Pregnancy and Childbirth, 10(1).

Lujiao Huang, J. Z. (2021). Association of gestational weight gain with cesarean section: a prospective birth cohort study in Southwest China, BMC Pregnancy and Childbirth, 21.

Lopez, U., Habre, W., Van der Linden, M., & Iselin-Chaves, I. (2008). Intra-operative awareness in children and post-traumatic stress disorder. Anaesthesia, 474–81.

Michael, Aziken,. Lawrence, Omo-aghoja., & Friday Okonofua. 2007 Perceptions and attitudes of pregnant women towards caesarean section in urban Nigeria. Acta Obstetricia et Gynecologica. 42-47

National Population Commission, (. [. I., 2019. Nigeria Demographic and Health Survey 2018 – Final Report, Abuja, Nigeria and Rockville, Maryland: NPC and ICF.

Osterman, J., Hopper, J., Heran, W., Keane, T., & van der Kolk, B. (2001). Awareness under anesthesia and the development of posttraumatic stress disorder. Gen Hosp Psychiatry., 198–204.

Roudsari, R., Zakerihamidi , M., & Khoei , E. (2015). Sociocultural beliefs, values and traditions regarding women’s preferred mode of birth in the North of Iran. International Journal of Community Based Nursing and Midwifery, 165.

Ryding, EL. ( 1993). Investigation of 33 women who demanded a caesarean section for personal reasons. Acta Obstet Gynecol Scand, 280.

Soderquist, J., Wijma, B., Thorbert, G., & Wijma, K. (2009). Risk factors in pregnancy for post-traumatic stress and depression after childbirth. Bjog, 672–80.

Udobang, W. (2018). Silence about C-sections: Nigeria has some of the highest infant and maternal mortality rates in the world, in part, because of taboos over Caesarean sections. Index on Censorship, 45-47.

Ugwu , E., Obioha , K., Okezie , O., & Ugwu , A. (2011). A five-year survey of caesarean delivery at a Nigerian tertiary hospital. Ann Med Health Sci Res., 77-83.

Unicef.org. (2021, July 13). Situation of women and children in Nigeria. From Unicef.org: https://www.unicef.org/nigeria/situation-women-and-children-nigeria.

Wijma, K., Soderquist, J., & Wijma, B. (1997). Posttraumatic stress disorder after childbirth: a cross sectional study. J Anxiety Disord., 587–97.