Caesarean section: The risk to mother and baby

You are pregnant and fast approaching due date. You have attended pre-natal clinics diligently and are sure everything is okay with the baby. But you face a dilemma; should you give birth naturally, or should you go for elective Caesarean section?

This is the new quandary facing many Kenyan mothers, and CS seems to be effortlessly winning over natural birth. But at what cost to both the mother and baby?

Pregnancy — and, by extension, delivery — has always been a tricky affair for women, so much so that American actress and comedienne Carol Burnett once equated giving birth to “taking your lower lip and forcing it over your head”.

However, recent advances in medical technology, coupled with Kenya’s growing middle-class preferences, are changing how women give birth. And also, as we shall see shortly, how their children live the rest of their lives.

ONE OF THE COMMON SURGERIES

Today, the World Health Organisation (WHO) notes, Caesarean section has become one of the most common surgeries in the world, with rates continuing to rise, particularly in high- and middle-income countries.

“Although it can save lives, Caesarean section is often performed without medical need, putting women and their babies at risk of short- and long-term health problems,” notes the international health agency.

It is estimated that 1.2 million babies were born in Kenya in 2016, a huge number of those through C-section. We could not get the actual figures, but the WHO as far back as 2013 estimated C-section delivery in Kenya to be at four per cent, against a recommended 10 to15 per cent.

However, due to lack of capacity to perform C-sections in some hospitals that offer maternity services, better equipped medical units like Kenyatta National Hospital (KNH) record C-section delivery rates that shoot up to 20 per cent.

Changing demographics have spawned an interesting trend, where mothers of a lower socio-economic class give birth naturally while the middle and upper classes go for C-sections, even in the absence of medical indication.

“Then there is a last section of mothers who are well-to-do and financially capable of affording all options who will opt for natural birth,” explains Dr Nelly Bosire, an obstetric/gynaecologist. “These mums will take Lamaze classes and seek out natural pain remedies, wanting the birth process to be as natural as possible. And this group is slowly expanding.” Overall though, says Dr Bosire, the demand for elective C-section is rising.

The choice of the method of delivery is often made by the mother-to-be in consultation with her doctor. In some cases, however, C-sections are planned because of medical reasons that make a natural birth risky.

“The woman may know in advance that she will need a C-section and schedule it because she is expecting twins or other multiples, or because she may have a medical condition, such as diabetes or high blood pressure, an infection that complicates pregnancy, such as HIV or herpes, or she may be experiencing problems with the placenta during her pregnancy,” explains Dr Bosire.

While most of the time C-sections are necessary, some are considered elective, meaning they are requested by the mother for non-medical reasons before she goes into labour. This means that a woman may choose to have a C-section if she wants to plan when she delivers or if she previously had a complicated natural delivery.

Although C-sections are generally considered safe and, in some situations, lifesaving, doctors say they carry additional risks compared with a natural birth.

“They are a major surgery which involves opening up the mother’s abdomen to extract the baby,” says Dr Lawrence Okong’o, a paediatric rheumatologist. “Of course it will be followed by physical complaints such as pain at the site of the incision and longer-lasting soreness.”

For pregnant women, knowing when a C-section is truly necessary is the million-dollar question. We all want to trust the opinion of our doctors about whether we should have one or not, and in some cases, C-sections are crucial.

However, the question that is likely to pop in a mother’s head is: which method is safer for both the baby and mother? Women should formally have the right to choose to give birth by Caesarean section, but they must also be offered counselling to help them make their decision.

WHAT ARE THE RISKS?

Dr Roseline Ochieng’, a neonatologist, says that since elective C-section often assumes that the gestation is correct, there is a risk of the mother delivering a premature baby, who might end up having respiratory complications.

When a baby is pushed naturally, the tight birth canal squeezes fluid from its lungs, making the baby less likely to suffer breathing problems at birth.

However, this process does not happen in C-sections, therefore babies may be more likely to have breathing problems such as asthma at birth and even during childhood. There is also a small risk that during C-section, the baby can get nicked during the surgery.

“Some studies have also suggested a link between babies delivered by C-section and a greater risk of becoming obese as children and even as adults for reasons that remain unclear,” Dr Lawrence Okong’o adds.

A study involving more than 38,000 people from 10 countries showed that the odds of being obese as an adult were 22 per cent higher for those born through C-section, compared with those born by vaginal delivery.

And the odds of being overweight (but not obese) as an adult were 26 per cent higher for those born by C-section. The study adds to a growing body of research linking C-section births to obesity.

Most current literature suggests that the gastrointestinal tract — the pathway food takes from the mouth, through the oesophagus, stomach, small and large intestine where the nutrients are extracted for the needs of the body — of a normal foetus is sterile.

During birth and rapidly thereafter, bacteria from the mother’s birth canal and the surrounding environment colonise the infant’s gut. Dr Okong’o explains that exposure at birth will, however, differ depending on the mode of delivery.

“During natural delivery, the contact with the maternal vaginal and intestinal flora is an important source for the start of the infant’s bacterial colonisation.

“On the flip side, during Caesarean delivery, this direct contact is absent, and non-maternally derived environmental bacteria play an important role for infants’ intestinal colonisation,” he says.

If the mother is the first person to hold the baby, it helps to colonise the baby’s gut with the mother’s normal body bacteria gut.

But natural delivery also has its cons. Although one advantage of a vaginal delivery is that a mother will have more early contact with her baby than a woman who has undergone surgery, and so she can initiate breastfeeding sooner, the stretching and tearing that occurs during a vaginal delivery can cause injury to the pelvic muscles that control the mother’s urine and bowel function, and hence cause fistula.

So, with this growing demand, between caesarean and natural birth, which one is safer? Dr Bosire says this question is a misnomer as it is not possible to make a comparison without looking at the reasons compelling one to have a Caesarean section over a vaginal birth.

“Hence if one opts for a vaginal birth where CS would be a better option, then obviously it is not the safer way to go,” she says.

However, she adds, during ante-natal clinics, one of the key components of care is preparation of a birth plan.

This is the time the mother and her partner have an opportunity for education, to be informed and make a decision on their birth plan.

PREFERRED METHOD

Because C-sections in first-time mothers often lead to repeat C-sections in future pregnancies, a natural birth is generally the preferred method of delivery.

However, Dr Bosire says that although doctors may play a role in determining the mode of delivery, more often than not, it is up to the mother to decide.

“Patient care decisions are no longer the premise of the doctor and the healthcare team but of a competent and informed patient.

“The patient has a right to full information on their condition, the treatment options available at the institution the patient is at, and options available in other institutions, their benefits and known risks, and the option to seek a second opinion,” she says.

A study titled Revisiting Natural Birth After Previous Caesarean-section, released last year, also found that women who have delivered babies through C-section can now safely opt for normal births thereafter.

The study, which was conducted between 2014 and 2015 at Aga Khan Hospital in Kisumu, reviewed delivery records of women who had undergone C-sections but later had normal deliveries, and found a success rate of 67 per cent.

“Natural birth after Caesarean is safe and can be offered as an alternative to elective Caesarean-section,” said Dr Bob Achila, one of the researchers.

C-SECTION AND SIZE OF BABIES: HUMAN EVOLUTION REDEFINED?

While Caesarean section deliveries have been found to save lives of mothers when babies are too large to be born naturally or if there are other health complications, they could also be affecting how humans are evolving.

Studies have shown that through the cliff-edge model of obstetric selection in humans, larger babies and mothers with narrow pelvis sizes died in labour in the past. That is no longer the case, meaning women with “risky” genes from mothers with narrow pelvises are being carried into future generations as mums-to-be.

Researchers estimate that cases of babies not fitting down the birth canal have increased from 30 in 1,000 in the 1960s to 36 in 1,000 births today because of this C-section effect. Dr Philipp Mitteroecker of the department of theoretical biology at the University of Vienna says this presents a long-standing question in the understanding of human evolution.

“Without modern medical intervention, such problems often were lethal and this is, from an evolutionary perspective, selection,” says Dr Mitteroecker.

“Our intention is not to criticise medical intervention, but it has had an evolutionary effect. Women with a very narrow pelvis would not have survived birth 100 years ago. They do now, and pass on the genes encoding a narrow pelvis to their daughters.”

It is estimated that between three to six per cent of births globally are obstructed because the mother’s pelvis is too small for the head or shoulders of the infant.

Over the past 50 or 60 years, this rate has increased to about 3.3 to 3.6 per cent.

That is about a 10 to 20 per cent increase of the original rate, due to the evolutionary effect. While it may not seem like a big difference, scientists warn that as the trend continues, the number will continue to rise.

It is believed that the sizes of women’s pelvises and babies’ heads were finely balanced over millions of years of human evolution, with hips unable to dip below a certain width if babies were to survive. But the increased use of Caesarean sections means all that is changing because women with hips of any size can now give birth to babies of any size.

CAESEREAN SECTION IN KENYA

Since 1985, the international healthcare community has considered the “ideal rate” for caesarean sections to be between 10% and 15%. In Kenya, 9% of children are delivered via Caesarean section.

Sh1 bn

NHIF payouts for Caesarean section operations have for the first time crossed the Sh1 billion mark in a year.

24,492

Official records show that 24,492 mothers covered by the National Hospital Insurance Fund opted for C-section in the first half of 2016, from 22,411 in a similar period a year earlier, representing a 9% increase.

Sh714.7 m

More C-sections saw the national health insurer pay Sh714.7 million in six months to the health facilities that performed the surgery, up from Sh432.1 million in a similar period the previous year.

61%

C-section accounted for 61% of the NHIF’s maternity costs and more than a third of the women covered by the fund opted for the operation.

Sh30,000

In 2015 the NHIF board increased the amount allocated to CS from Sh18,000 to Sh30,000. The fund also pays Sh10,000 for normal delivery, having increased it from Sh6,000.

graphic: Michael Mosota

WHY WOMEN OPT FOR CS

AGE

10% of women aged between 35 and 49 years will more likely consider delivery by C-section, compared to 6% of those aged 20 and below.

BIRTH ORDER

An estimated 13.1% of women delivering their first child will opt for a C-section, compared to only 4% of those who have had previous pregnancies.

RESIDENCE

More women (15%) living in urban settings will opt to deliver through C-section than those living in rural parts of the country (5%).

EDUCATION

At least 15% of women with secondary education and above opt for a Caesarean section, compared to only 4% of those who did not complete their primary education. Only 2% without education undergo a C-section.

WEALTH

Moneyed moms (19%) and 12% of those in the upper middle class quintile prefer having a Caesarean section than normal delivery.

FOR YOUR INFO

YOU NEED A C-SECTION IF: You have had a C-section in a previous pregnancy or other surgeries on your uterus. Also if there are problems with the placenta, which grows in your uterus and supplies the baby with food and oxygen through the umbilical cord. Placental problems can cause dangerous bleeding during vaginal birth. And, finally, if you have an infection, like HIV or genital herpes.

HOW CS AFFECTS YOUR BABY

Breathing difficulties: Contractions of labour help to prepare the baby’s lungs for respiration at birth. During each contraction of labour, there is temporary reduction in the amount of oxygen that is available to the foetus. These labour contractions reduce the amount of oxygenated blood that is passed through to the placenta, causing the baby’s heart rate to slow down. To adapt to this level of stress the baby increases its production of catecholamines, the neurotransmitters produced in the adrenal glands. When you feel stressed, these hormones increase heart rate, blood pressure, breathing rate, muscle strength, and mental alertness. This adaptive response allows the baby to receive the same amount of oxygen as before labour contractions. It also prepares the baby’s lungs to breathe on their own at birth by absorbing the liquid in their lungs. Babies born by a scheduled Caesarean, however, have lower levels of catecholamines than those born vaginally.

Chronic illnesses: Specifically asthma, type 1 diabetes, and obesity. Being born by Caesarean may slightly increase the risk of your baby developing asthma in childhood. Scientific evidence suggests that C-section may also slightly increase the baby’s risk of becoming overweight.

Delayed attachment: Holding, touching and caring for healthy, sick, premature infants or those with congenital problems enhances attachment between mothers and babies. In fact, the World Health Organisation encourages skin-to-skin contact between mother and baby as soon as possible after birth for at least one hour and until the newborn has successfully completed the first breast feed. The mother’s body heat keeps the baby warm, reduces the new-born's crying, stress and energy use. Skin-to-skin contact also helps with the baby’s metabolic adaptation and stabilises its blood glucose level.

Intestinal micro-ecology: Current literature suggests that the gastrointestinal tract of a normal foetus is sterile. During birth and rapidly thereafter, bacteria from the mother’s birth canal and the surrounding environment colonise the infant’s gut. On the flip side, during Caesarean delivery, this direct contact is absent, and non-maternally derived environmental bacteria play an important role for infants’ intestinal colonisation. If the mother is the first person to hold the baby rather than a staff person, it helps to colonise the baby’s gut with her mother’s normal body bacteria gut.

Neonatal death: In 2006 researchers examined live births between 1999 and 2001. They reported that newborns of mothers who had a planned Caesarean were more likely to die in the first four weeks of life (1.77 per 1,000 births) than newborns of mothers who had a vaginal birth (0.62 per 1,000 births). That is almost three times the risk.