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When Alice Ogbara recently leaked the details of her cesarean section to a group of women, it was not an ordinary "birth story" shared with friends: she was doing something that many would consider risky. It's because she was talking about surgery that some women would not want to suffer, even if they knew it could save their lives.
"When I walked around [into the operating theatre]I saw everything they would use on me and I cried, "Ogbara told others. She said that she was afraid of suffering irreparable damage. Then a sheet was placed on her belly. "The next thing I heard was that my baby cried," she recalls, eliciting congratulatory applause from the women around her.
Beyond this courtyard in Lagos, Nigeria, Ogbara may not share his story so readily. Concerns about the safety of surgery, combined with religious and social factors, mean that cesareans are stigmatized in Nigeria. This forces many women to resist surgery – or to hide it when they undergo it. Ogbara even kept the secret of her caesarean section with her family members. "If you tell us Nigerians that you're going to go through a cesarean, they'll tell you," God do nothing, "Ogbara said.
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The meeting she attended was led by Mamalette, a Nigerian non-profit organization that supports pregnant women and is trying to reduce maternal mortality rates in Lagos. Part of this effort is to address the stigma surrounding birth that prevents women from accessing life-saving care.
In Nigeria, 58,000 women die each year in childbirth, making it the fourth highest maternal mortality rate in the world. Part of the problem is the low rate of caesarean section in the country: barely 2%. The overall rate is 21%. In the meantime, there is only one doctor for every 6,000 inhabitants in the country.
Mamalette aims to provide women with what under-resourced health workers often can not get: supportive health education and an ear to their concerns. Their grassroots approach shows early success in improving health outcomes for pregnant women. But the small organization faces considerable challenges.
Global disparity
In a global context where rates of caesareans are rising rapidly, Nigeria's numbers stand out. Between 2000 and 2015, caesarean section rates almost doubled worldwide. In countries such as the Dominican Republic, women are currently undergoing surgery in more than 50% of cases. In North America, it amounts to 32.6%; in the United Kingdom, 26.2%.
In West Africa, only 4.1% of births on average involve cesarean delivery, and Nigeria's rate is half as high.
To effectively prevent maternal mortality, the rate of caesarean section of a country should not be less than 5%, according to the World Health Organization. Caesareans are essential to prevent obstructed labor in cases where the woman's pelvis is too small, the baby in a siege position or too big to exit the birth canal. Without intervention, a contracted baby can severely break his uterus or cause tears that cause catastrophic bleeding.
"I think it's the health indicator that has the greatest possible disparity between overuse and underuse," says Carine Ronsmans, an epidemiologist with the London School of Hygiene and Tropical Medicine and author of recent reports detailing overall increase in the number of caesareans.
A very large number of caesareans can be of concern because caesareans can increase the risk of diseases such as placenta previa, which can cause heavy bleeding. At the same time, "so many women are still dying to be denied access," says Ronsmans. "We really can not afford to forget these women."
In Nigeria, barriers to access are particularly important in rural areas, where about 58% of deliveries are with unskilled midwives.
In urban centers with more hospitals, cost and stigma are the main barriers. The stigma is motivated by the idea that vaginal birth is aligned with femininity, while caesareans are not – common idea in countries like the UK, too.
In Nigeria, this is what religion has strengthened: Christian women generally hear that giving birth vaginally as a "Hebrew woman" is a sign of strength and competence. This comes from a passage in the Bible, which tells the story of "vigorous" Hebrew women who deliver stoically without giving birth from midwives.
This mythical ability to deliver vaginally – and without supervision – has been recognized as a symbol of maternal virtue in Nigeria. "Nigeria is a deeply religious country and everything is very spiritual," said Adepeju Jaiyeoba, founder of the Nigerian Brown Button Foundation, which works to reduce the number of maternal deaths.
Hospitals regularly meet women who – fearing to shame their family – simply refuse the surgery. Women often have limited control over their own births: a case study conducted in a Nigerian hospital found that in 90% of cases, it is women who should sign the consent form allowing them to undergo a caesarean section – by placing firmly the decision masculine hands.
In other countries such as the United Kingdom and the United States, the situation may not be as extreme. But women continue to be stigmatized to have caesareans.
And high quality obstetric care does not necessarily translate into ideal conditions for pregnant women. In 2018, Birthrights, a charity for mother's rights, found that almost three-quarters of UK public hospitals do not have a clear policy for women to request planned caesareans, which contravenes national clinics. Birthrights think this has a stigmatizing effect, especially when women have specific reasons to avoid vaginal deliveries, such as a history of sexual assault or mental health issues, says Amy Gibbs, Executive Director. of Birthright.
"Women should be the main decision makers at birth. This right to choose what will happen to your body is so fundamental. "
Mamalette is also fighting for this principle in Nigeria.
Health advocates
Anike Lawal is installed in the quiet and cool office of Mamalette, in the technological center of Yaba district, in Lagos, right next to a chaotic street where taxis and three-wheeled motorcycles sneak into a bottled traffic.
A thoughtful, soft-spoken woman, she says, launched Mamalette as an online community where mothers could support each other. "I did not try to save anyone's life," says Lawal. But drawing from the large community of women has shown how even urban mothers are at risk of childbirth. "When we talk about maternal loss, we never think of women living in cities, women who have a smartphone or Facebook," she says.
In 2017, Lawal began recruiting mothers to help local women in their communities safely during pregnancy. This was the focus of today's 20-member team, which Lawal calls the "Mamalette Champions".
These mentors, trained by midwives, nurses and doctors, are currently working in 20 disadvantaged urban communities of Lagos and another in the city of Ibadan, serving more than 300 people during individual home visits. . They ensure that women attend antenatal classes and register at the hospital to give birth instead of using traditional birth attendants. Often, they go to the hospital with women when they give birth. "In a country where we do not have enough hospitals or doctors, preventive care is very important. That's what we do, "says Lawal.
In a unique way, Mamalette also creates a safe space where women can talk about taboo topics around birth, such as caesareans. In the communities they serve, they are often the first gateway for women to discuss these concerns – ranging from stigma to the quality of surgical care, which may be low in some settings.
"Mamalette is like an intermediary between the health system and people," says Blessing Kolade, a former mentor who is now working with Mamalette's program team. "The health care 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 misconceptions are left out and that stigma is no longer disputed. Many women who need a Caesarean section are considering it for the first time while they are already in labor. At this point, they are less likely to accept surgery because they are dealing with deeply held beliefs that they will shame their families. "Because of this stigma, you will see someone who is about to die and still refuses a cesarean, because she does not want to experience all that," says mentor Oluchi Anumni.
Mamalette tries to solve these problems before they reach this decisive stage. Mentors, specially trained to dispel misconceptions around caesareans, clearly explain why women may need a caesarean section, such as having a small pelvis or medical conditions such as preeclampsia. This eliminates the shame of the equation and provides women with facts that provide them with ammunition against the judgment that they might receive.
Some mentors even end up defending the decisions of their escorts in the hospital. "We had advocates who advocated for pregnant women with their families if they had to undergo medical procedures," says Lawal.
Anecdotally, women noticed that their group members were much more receptive to caesareans. Mentor Adenike Lasisi-Opaleye says she invites women who have had a caesarean section to come to show scars that their abdominal scars are damaged in order to dispel the myths about what cesarean sections actually do. "They had the impression that caesareans were forbidden. They are now informed that [it’s] not a death sentence, "says Lasisi-Opaleye. The data collected by Mamalette also show that the majority of women they care for are now giving birth in health facilities, according to Lawal.
"I can proudly say that so many women have escaped death thanks to what they have learned," Anumni adds.
Complex solutions
But when it comes to maternal health, it is not enough to tackle cultural and social barriers to cesareans.
Recent research has found that caesareans in sub-Saharan Africa are up to 50 times more fatal than in high-income countries. According to Salomé Maswime, an obstetrician, gynecologist and lecturer at the University of the Witwatersrand, involved in research, it is mainly about poorly treated hemorrhages and sloppy anesthesia.
"As a doctor, I really feel that access is the starting point. But I'm nervous to just say access by itself, "says Maswime. "We must pay attention to the quality of surgical care that women have."
She believes that if care improves, the stigma associated with surgery will also be reduced: "I do not think it's as easy as counseling women," said Maswime. "It's a complex problem that requires complex solutions."
The cost of medical care is also a deterrent to getting surgery in Nigeria. Some countries have tried to improve access by making caesareans free. In Mali and Benin, the removal of user fees has been shown to increase the number of births to hospital and lead to better health outcomes for women and their infants. In Nigeria, similar changes are occurring: the Lagos State Government, for example, recently announced the launch of a new health insurance scheme that will release caesareans.
Still in Lagos State, some hospitals are now referring women who refuse a caesarean section to social workers to discuss their concerns, says Aduragbemi Banke-Thomas, a health policy researcher based at the London School of Economics and Lagos. State University. He believes that lending women a listening ear is a powerful approach. "What we really need to do is try to bring women together as partners," he says.
In the UK, a similar "partnership" approach is helping hospitals improve women's access to planned caesareans. Rather than outright forbidding planned caesareans – as their birthright discovered, which is striking in 15% of hospitals – some institutions now say that if women have received the information they need to make a choice enlightened, their decision of Caesarean section will be respected.
Nina Johns, an obstetrician at the Birmingham Women's Institute, has taken this new approach. "It provides this opportunity to work together, rather than adversely."
Whether in Nigeria or the UK, the fundamental problem and the solution are the same, says Amy Gibb of Birthright. "Often the woman's right to choose what happens to her is lost," she says. "The way to get this right is to put women at the center of choices about their care."
A legacy of change
Mamalette recognizes that the task they face is too heavy for a single small organization working in a multitude of communities. But they think that by giving women more information, they also bring a more sustainable type of change.
"Something that Mamalette does, that we have not really seen, is to give women the identity," said Mamalette's former mentor Olamide Ekpenyong. "We try to let women know that we have to be bold. Do not let society define you. "
Encouraging women to assert their rights to life support crystallizes this goal. "With this knowledge, they educate others," says another mentor, Christiana Ogunbowale. "Some of them have girls, so Mamalette is already preparing for the future of women."
Alice Ogbara says that her own vision has changed. Now, her daughter is one year old and Ogbara is not so cautious when she tells people how she gave birth.
"I tell people around me, I share my own experience with them," she says. She is very careful to inform women that if they need a cesarean, they only need to go to trusted hospitals, for example. But she is also encouraging. "A cesarean is not a bad thing," she tells people. "This is only a second way to deliver."
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The presentation of this article was made possible thanks to the funding of the European Center of Journalismof the Grant for reporting on innovation in development program.
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