Harriet S. Okot
21 September 2008
Uganda has no system in place to monitor caesarean births, an increasingly popular method of delivery, which has blossomed into a billion shilling business, benefiting mainly private clinics and hospitals.
An investigation by Sunday Monitor shows that approximately 4,000 births a year take place in government hospitals while a conservative estimate puts the estimate in private clinics at four times that number.
But according to the Ministry of Health, it has no system to assess not just the number of C-section births in private clinics but the conditions under which they are conducted.
There is also is no strict rule of thumb to the number of C-sections that a woman can have. Though doctors advise a woman to stop after four operations it may exceed this number in some cases.
Several women interviewed by Sunday Monitor, who preferred not to be named so as to protect their privacy, expressed concern that money-driven clinics put them and their families under undue pressure to have a C-section. Others, however observed that it is a choice that has gained some currency amongst some urban women or what are commonly referred to as 'too posh to push' mothers.
Our investigations suggest that Uganda may well be exceeding the World Health's Organisation's set annual average for C-sections. WHO's guidelines provide that C-sections be performed on not more than 15% of mothers who deliver but this is not what is being mirrored on the ground, especially within the private health delivery sector. Because the health minstry does not monitor C-section occurence no figures exist but anecdotal evidence suggest that Uganda is well above the 15 percent maximum.
A number of factors may explain the increase in the procedure but advancement in medical technology where women no longer have to be placed under general anaesthesia before being operated on, and increased medical awareness could explain this trend.
A survey by this newspaper found that a C-section in the private wing of a government referral hospital costs between Shs700,000 and Shs1.5 million while in posh private facilities such as Kololo Hospital, Paragon Hospital and International Hospital Kampala the cost ranges between Shs1.2 million and Shs3.5 million depending on the choice of additional ante- and post-natal services a mother may choose to have.
This sort of big money could be influencing private health care providers to increasingly encourage expectant mothers to opt for a C-section over and above real safety and health considerations.
Dr Ramathan Lukoda, a former obstetrician in the Ministry of Health's reproductive health department, who is currently consulting for his former employer, says the free market is largely to blame for the trends as private clinics determine their own prices.
"The price shoots up depending on the length of one's stay in a hospital, the medical personnel performing the operation and this refers to numbers and one's professional skills, what equipment they are using and where the operation is being conducted," he says.
The question then is, how in the face of an unregulated sector, does the government establish whether women are being unnecessarily subjected to caesarean births in private facilities and the private sections of public national referral hospitals, and thus ensure that they are not being exploited.
Dr Mike Kagawa, a member of the Obstetrics & Gynecology Association in Uganda and a lecturer at Makerere University Medical School, nevertheless says the more educated women are the ones opting for elective caesarean sections (the "too posh to push" group)
Their main motivation being the simplicity of the procedure and its touted benefit; staying young by keeping the integrity of the birth canal.
Dr Kagawa adds that the modern woman has a strong desire to be in control and have the power over when their baby is born. C-sections offer this even for women of advanced age. A woman can choose on which day her baby will be born. There is also the issue of skipping labour pains.
"In the beginning, the operation was done to get a baby out of a dead mother, as it was believed that a woman should not be buried with a child in her womb. With the advancement of medical technology the operation is being done more and more as way of assisting women who have complications during labour to give birth," Dr Kagawa explains.
The health ministry, however, has clear guidelines on when one must have a C-section, most of them medical emergencies, like when the baby is lying in the wrong position or if a woman has had a pervious caesarean and is at risk of scar tear/rapture if she were to try to push and complications to do with the umbilical cord or when the mother is HIV positive so as to limit chances of mother-to-child transmission of the virus.
Doctors would also perform a C-section in the event that a mother goes into prolonged labour that tires out the baby or if it is a young mother who is not fully physiologically developed and therefore cannot safely deliver naturally.
But there are risks involved with this procedure, for instance; the effects of exposure to anaesthetic, the increased chance of one developing an infection, bowel injury during surgery, uncontrolled bleeding and intra-uterine disruption. For the young child, the danger of respiratory distress syndrome is ever present.
And then, compared to C-sections, women who have natural births have a faster recovery period, less of a risk of respiratory distress syndrome for their babies, faster bonding between the mother and baby (because she gets to hold her baby immediately), lower costs and shorter stay in hospital.
However, with C-sections gaining currency for any number of reasons, stricter regulation and more awareness is becoming increasingly important to clarify the choices for expectant mothers.
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