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BBC – Future – Why do women reject this operation?

When Alice Ogbara recently relayed the details of her caesarean section to a group of women, this was not a common "birth story" that happened to be shared amongst friends: she did something that many would consider risky. That's because she talked about an operation that some women would refuse, whether they knew it could save their lives.

"When I left [into the operating theatre]I saw everything they were I was crying," said Ogbara to the others. She said she was afraid of being damaged irreparably. Then a sheet was placed over her stomach. "The next thing I heard was that my baby was crying," she recalled, calling for the women around her to congratulate her on the applause.

Beyond this farm in Lagos, Nigeria, Ogbara would not like to tell their story. Concerns about the safety of the operation in connection with religious and social factors cause caesarean sections in Nigeria to be stigmatized. This causes many women to resist the operation ̵

1; or to hide it when they cope with it. Ogbara even kept her caesarean secret from family members. "If you tell us Nigerians that you're going through the C-section, they'll tell you, 'God forbid," says Ogbara.

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The meeting she attended was run by a Nigerian non-child. Profit called Mamalette, which supports pregnant women and seeks to lower maternal mortality in Lagos. Part of this effort is to combat birth stigmata that affect women's access to life-saving care.

Every year, 58,000 women die at birth throughout Nigeria. This gives the country the fourth highest maternal mortality rate in the world. Part of the problem is the country's low caesarean rate: only 2%. The worldwide rate is 21%. There is now only one doctor per 6,000 people in the country.

Mamalette wants to provide women with what underserved healthcare workers often can not do: providing supportive health education and listening to their concerns. Their grassroots approach shows that pregnant women achieve success in improving health outcomes early on. However, the small organization faces significant challenges.

Global Disparity

In the global context where cesarean rates are skyrocketing, the Nigerian figure stands out. Between 2000 and 2015, caesarean rates almost doubled worldwide . In countries such as the Dominican Republic, women are now operated in more than 50% of cases. In North America, it is 32.6%. in the United Kingdom 26,2%.

In West Africa on average only 4.1% of births involve caesarean section, and the Nigerian rate is half that.

To effectively prevent maternal mortality, the caesarean section rate of a country should not be exceeded below 5%, says the World Health Organization. This is because if a woman's pelvis is too small, the baby is in a closed position, or too tall to leave the birth canal, medical caesaris is necessary to prevent labor. Without intervention, a constricted baby can fatally injure the uterus or cause tears that cause catastrophic bleeding.

"I think this is the health indicator with the biggest possible difference between overuse and underuse," says Carine Ronsmans, an epidemiologist at the London School of Hygiene and Tropical Medicine and an author of recent reports on the global increase in health caesarean section.

A very high number of cesarean sections may be of concern, as caesarean sections may increase the risk of conditions such as placenta previa, which can cause severe bleeding. At the same time, "so many women still die because they have no access," says Ronsmans. "We really can not afford to forget these women."

In Nigeria, access barriers are particularly high in rural areas, where approximately 58% of deliveries are made with unskilled midwives.

In urban centers with more hospitals, costs and stigma are the primary obstacles. The stigma is based on the assumption that vaginal birth is consistent with the age of the woman, whereas caesarean sections are not a common idea in countries like the UK. This is strengthened in Nigeria by religion: Christian women in general Hear that a vaginal birth like a "Hebrew woman" is a sign of strength and competence. This is evident from a biblical passage that tells the story of "strong" Hebrew women giving birth to midwives stoically and unsupervised.

This mythical ability to give birth vaginally and unattended was held up as a symbol of maternal virtue in Nigeria. "Nigeria is a deeply religious country, and everything is very spiritualized," says Adepeju Jaiyeoba, founder of the Brown Button Foundation in Nigeria, which works to reduce the deaths of mothers from the operation. Often, women have limited control over their own births: a case study from a Nigerian hospital found that in 90% of the cases, women believed that men should sign the consent form for undergoing caesarean male hands.

In other countries, such as the United Kingdom and the United States, the situation may not be that extreme. However, women still suffer from a stigma because they have cesarean section.

And a high quality obstetric does not necessarily mean that pregnant women have perfect conditions. In 2018, Birthrights, a maternal rights charity, found that nearly three-quarters of UK public hospitals lack a clear policy that women can apply for scheduled caesarean sections, in violation of national clinical guidelines. According to Amy Gibbs, managing director of Birthright, this has a stigmatizing effect – especially if women have certain reasons to avoid vaginal delivery, such as a history of sexual assault or mental health problems.

"Women should be the main decision at birth. The right to choose what to do with your body is so fundamental. "

Mamalette also fights for this principle in Nigeria.

Health Attorneys

Directly on a Chaotic Road Where three-wheeled Keke taxis and motorcycles wind through the traffic, Anike Lawal sits in Mamalette's quiet, cool office in the Tech Hub, Yaba district in Lagos.

A thoughtful, quietly spoken woman, she says, has launched Mamalette as an online provider community where mothers could support each other. "I did not want to try to save someone's life," says Lawal. However, tapping into the widespread community of women showed her the risk that even urban mothers faced at birth. "When you talk about losing your mother, you never think about women who live in cities, women with smartphones and Facebook," she says.

In 2017, Lawal began recruiting mothers to help indigenous women in their communities safely through pregnancy. From this developed today's 20-member team, which Lawal calls the "Mamalette Champions".

These mentors, trained by midwives, nurses and doctors, currently work in 20 urban poor communities in Lagos and one in the city of Ibadan to serve more than 300 people through one-to-one home visits. They ensure that women visit their antenatal classes and enroll in hospitals to give birth instead of employing traditional obstetricians. They often visit a hospital with women when they go to work. "In a country where there are not enough hospitals or doctors, prevention is very important. That's what we do, "says Lawal.

Mamalette uniquely creates a safe space for women to talk about birth-related issues such as birth issues. B. Caesar. Often in the communities where they work, they are the first port of call for women who want to talk about these concerns – from stigmatization to the quality of surgical care, which can be low in some settings.

"Mamalette is like a mediator between the healthcare system and humans," says Blessing Kolade, a former mentor who now works in the Mamalette program team. "The healthcare system is so overwhelmed that even health care workers do not have time to break down the information. Women can not open; they can not ask questions, "she says.

This means that misunderstandings and stigmatization go unchallenged. Many women who need a caesarean section think about it for the first time when they are already in labor. At this point in time, they are less likely to accept the operation because they are firmly convinced that they will shame their families. "Because of this stigma you will see someone who is at the end of death and still refuses a caesarean because she does not want to go through all this," says Mentor Oluchi Anumni.

Mamalette tries to address these issues before they come to this fateful stage. Mentors who are specifically trained to dispel misunderstandings about caesarean sections clearly explain the reasons why women may need a caesarean section; As a small pelvis or diseases such as preeclampsia. This takes the shame out of the equation and provides women with facts that give them ammunition against the judgment they may receive.

Some mentors even defend the decisions of their mentees in the hospital. "We had champions who worked with their families for pregnant women when they needed medical intervention," says Lawal.

Anecdotally, her group members are much more susceptible to Caesarean section. Mentor Adenike Lasisi-Opaleye says she invited women who had Caesarean sections to come and show mentees their belly scars to dispel the myths about what cesarean sections really do. "Her perception was that Caesarean sections were a no-go. You are now informed that [it’s] is not a death sentence, "says Lasisi-Opaleye. The data collected by Mamalette also shows that the majority of women they care for are born in health facilities, according to Lawal.

"I can proudly say that so many women have escaped death by the things they have learned," Anumni adds.

Complex solutions

But when it comes to maternal health, it is not enough just to eliminate cultural and social barriers to caesarean sections.

Recent research has shown that across sub-Saharan Africa caesarean sections are up to 50 times more lethal than in high-income countries. This is mainly due to untreated bleeding and botched anesthesia, says Salome Maswime, obstetrician, gynecologist and lecturer at the University of Witwatersrand, who has been involved in the research.

"As a doctor, I feel access is really the starting point. But I'm nervous just saying "access on my own," says Maswime, "we need to pay attention to the quality of women's surgical care."

She believes that improving care also includes having surgery "I do not think it's that easy to advise women." Maswime says, "It's a complex problem that requires complex solutions."

The cost of medical care is also on Obstacle to surgery in Nigeria Some countries have tried to improve access by freeing caesarean sections In Mali and Benin, reducing the cost of use has increased hospital birth and improved health outcomes for women and their families In Nigeria, similar changes are taking place: for example, the state government of Lagos recently announced the introduction of a new health insurance scheme Stems, which allows the release of Caesarean sections.

Also in the state of Lagos, some hospitals have women rejecting Caesarean sections Aduragbemi Banke-Thomas, a health researcher at the London School of Economics and Lagos State University, said social workers to discuss their concerns. He believes that giving women an open ear is an effective approach. "We really need to try to bring the women as partners," he says.

In the UK, a similar "partnering" approach helps hospitals improve women's access to planned Caesarean sections. Instead of banning planned caesarean sections immediately – as Birthrights noted in 15% of hospitals – some establishments state that women, when provided with the information they need for an informed decision, make their decision to take a planned caesarean section respected.

This has alleviated the relationships between patients who may have previously been stigmatized or worried about the lack of control over their births, and doctors who felt compelled to overcome women's concerns, says Nina Johns, an obstetrician at Birmingham Women's Hospital, which has adopted this new approach. "It's an opportunity to work together instead of opposing each other."

Whether it's Nigeria or the UK, the fundamental problem and solution are the same, says Amy Gibb of Birthright. "Often the woman's right to decide what happens to her is lost," she says. "The way to fix this is to put women at the center of their due diligence decisions."

A Legacy of Change

Mamalette realizes that her job is for a small organization Too much work in just a pinch of communities. However, they believe that by empowering women with information, they also bring about a longer-lasting change.

"Mamalette does something we have not really seen, it gives women identity," says former mentor Mamalette Olamide Ekpenyong. "We try to let women know that you have to stand and be courageous. Do not let society define you. "

Encouraging women to claim their right to life-saving care crystallizes this goal." They use this knowledge to educate others, "says another mentor, Christiana Ogunbowale." Some of them have girls, so prepare Mamalette is already preparing the future for the coming women. "

Alice Ogbara says her own attitude has changed, now her daughter is one year old, and Ogbara is not so careful when it comes to people

"I tell people around me, I share my own experiences with them," she says, being cautious and advising women to go to trusted hospitals only if they need a caesarean section. But she is also encouraging. "A caesarean is not a bad thing," she says. "It's just a second way to deliver something."

Reporting f This article was funded by the European Journalism Center Innovation in Development Reporting Grant Program .

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