Caesarian section rate: Which way, Kenya?

Recently, a local daily paper ran a story on the increasing rate of caesarian sections in Kenya, eliciting a myriad of responses from all and sundry.

For the practitioner serving the marginalised populations, who is still grappling with the delays in the woman accessing maternity care, many of his/her patients will most likely fail to access a necessary caesarian section in time, if at all! Their concerns are not how high the national rate is, but how to ensure the much-needed intervention is accessible.

For this patient, the free maternity government directive to provide care under the Linda Mama scheme has brought much needed respite, with women being able to access skilled delivery, hence increasing the number who access the surgery. Many level three hospitals in the country that provide delivery have been upgraded in the past 10 years to level four, equipped with operating theatres to provide caesarian sections as close to the people as possible.

In line with increasing access, many affordable private hospitals have sprouted across the country, providing maternity care under the Linda Mama programme, too. For these facilities, very few patients in the past could afford surgery there. Whenever the need arose, they would be referred back into the public health system. Currently, these facilities are able to complete the care because of the reimbursements for service through the National Health Insurance Fund. It is therefore expected that with these factors, the caesarian section rate will increase exponentially for a while before leveling off. However, there has been concern over caesarian section rate due to other factors that may not be deemed to be so noble.

Top on the list is the perceived notion that practitioners may be performing unnecessary caesarian sections for monetary gain. This would very well hold water, were it not for the fact that the number of women who afford private care at the level where their doctor is paid directly make up an almost insignificant minority.

For many private hospitals providing care under the Linda Mama programme, the reimbursements are so drastically low that it would not make economic sense to do an unnecessary surgery. The cost of running a surgical unit, the drugs required, the level of manpower necessary to execute one such surgery, plus a three to four day stay at the hospital for the mother, does not make it a motivation at all.

This scenario therefore leaves a very small majority of women, served by the exclusive private practitioner billing for work done. These numbers haven’t quite convinced me they can tip the scales dramatically as yet.

The other scenario envisioned is of the empowered woman who opts for a caesarian delivery over a vaginal birth, with no medical indication. Again, for public facilities, this is not an option. The available resources as of now do not even have the capacity to support the number of women in need of a caesarian section, whom they attend to, let alone adding those who want the surgery by choice.

This again leads back to the small majority of financially empowered women who can afford to pay for the surgery in facilities that have the resources to support them. Of note is that these are the mothers who generally tend to have fewer births too, hence are not a largely recurring number in the system yet.

This factor is expected to be the biggest future contributor to increasing caesarian deliveries, if we are true to the practice of “Patient-centered care” that is firmly taking root across the world. We must take cognizance of the fact that the fight by women, for autonomy over their bodies, is at an all-time high, if the response to the overturning of the “Roe vs Wade” ruling at the Supreme Court in the United States is anything to go by. The choice of how to deliver will no longer be left to medical practitioners!

The one other completely ignored factor is the subtle but sustained shift in women’s choices over when to have children and how many! The household size in Kenya has continuously decreased. It means women are having fewer children. Therefore, the long-considered risk of multiple caesarian sections is slowly being eliminated as many women settle for two to three children.

Further, many are now having children when they are much older, in their late thirties to early fourties. An age where medically indicated caesarian section rates drastically go up. No 45-year-old woman is going to take a chance with unpredictable labour for a baby conceived via expensive assisted reproductive technologies, especially after multiple failures!

The existing WHO standard caesarian section rate of 10 per cent to 15 per cent per country was based on review of evidence looking at population maternal and infant mortality rates. This means that this range was justified by how many deaths were averted by caesarian section. This fails to tell the whole story. Let us include how many bad outcomes were averted for both mother and baby. This will include complications such as birth asphyxia, cerebral palsy, fistula, genital tract injuries, psychological trauma and many others. It is about time the WHO technical working group reassembled for another review!

Dr Bosire is an obstetrician/gynaecologist