- •There is increased recourse to caesarean section in health facilities in Mali and Benin
- •Some women request a caesarean section during their labour because they are suffering
- •Inadequately resourced facilities lead to staff suffering and overuse of technology
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- Institut National de la Statistique et de l'Analyse (INSAE) and ICF
- United Nations
- Department of Economic and Social Affairs
- Population Division
- Institut National de la Statistique
- Cellule de Planification et de Statistique Secteur Santé-Développement
A sociological study of the use of a biomedical technology in two low-income countries
Context of caesarean policies in Benin and Mali
Workshops with birth caregivers
Participant observation in health facilities
Fear and reluctance of women and their family to give birth by caesarean section
Women are afraid of caesarean section. When you mention a caesarean section, sometimes they run away! They run away first before coming back. They run away! Families are doing the same. There is a psychosis when we tell you we will operate; no, there is a great fear, as I mentioned (Beninese midwife, 53 years old).
My husband refused. He refused a caesarean section. And so did my parents; everyone refused. They said they're scared. They're afraid for my life (woman giving birth for the first time, 26 years old).
When I was told I was going to have a caesarean section, I was scared. Too scared. I thought that, during the caesarean section I would die.
They said I'm going to have another caesarean section. Really, that really hurt me, because I was hoping to deliver vaginally. When I was told that, I cried; I started crying. It hurt too much because I really hoped to deliver vaginally. Most often, women are afraid – we think our lives are in danger, that things can go wrong. That's why we're afraid. We think we can die easily.
[Women] don't like it because it scares them, and in general, you know, Mali is a country with high fertility, so if you start giving birth by caesarean section, it will be difficult to go to six children because there may be medical indications for tubal ligation (40-year-old male Malian obstetrician).
Women’s request for caesarean section and maternal distress
with the policy of access to free caesarean sections, women come to the hospital. As soon as the contractions begin, they come to the hospital. They say, ‘Operate on me, operate on me, operate on me’. You see, they scream, and they say, ‘Go ahead and operate; I cannot push any more’. I see a lot of women saying that.
March 2017, 00h30: Arrival of a woman referred for haemorrhage and uterine rupture. Pale conjunctives +++. Arrived by motorcycle taxi, carried by the driver. Needs prescriptions, blood, but the family is absent. Only the mother-in-law is in the hospital yard; she says she has only 500 FCFA-0.85 USD, nothing more. The husband must come, but he is unreachable. The woman bleeds to death being watched by other women in labour around her’ (Cotonou, field notes).
Even last night, I had a case like that. A woman who tells me, ‘Go ahead and operate on me’. It's the pain that does that because she cannot bear the pain. She is there, it takes time, she has pain, so she wants to have peace. So in this context, she requests a caesarean section.
Yes, yes, there are women who request caesarean sections. Even the women who are in the delivery room, when they are tired of pushing, they ask for a caesarean section. They do not want to make any more effort.
There is no epidural, there is no childbirth without pain, so young people live with this fear (Beninese midwife, 46 years old).
Preventive caesarean sections due to under-resourced conditions
In our daily practices, we have concerns about the pelvis, and since we don't have the means to explore the pelvis, this often leads to caesarean sections.
The problem in the public sector is that the equipment is not renewed. We had four cardiotocographers here in the past, and really, we were comfortable working. And then, the equipment became degraded, and since then, no one wants to update the equipment. In the past, we were really doing obstetrics, and we were really trying to deliver the scarred uterus vaginally. Now with all the problems we have, only one operating room and all that, we don't try any more! We don't try any more! And when the equipment deteriorates, no one wants to try any more. And also, people are not responsible for the equipment. And when things get bad, the authorities don’t want to renew.
And sometimes we wonder if we are regressing... at a certain point, we were a little advanced, and then, gradually, everything stopped; we came back as before... So, we go back to the archaic methods we used before.
Lack of staff motivation and ethical breakdowns encourage inappropriate use of medical technology
Women arrive here at a terminal stage of labour; we only register the deaths.
How can one work in these conditions? We turn in a vicious circle, and no one finds a way out. We're here, we're surviving, we're stressed because, well, you see someone dying, and you cannot do anything; so, before, we contributed with our money to save lives. And at some point, we said to ourselves, ‘We will continue to contribute until when?’ (female obstetrician, 54 years old, Benin).
midwives push for caesarean section because it frees them up. It decreases the number of women in the delivery room, because when we decide to have a caesarean, we prepare the kit, the patient goes to the surgical theatre, and then it's over. And then the delivered woman goes to the postsurgery room. But when a woman is in the labour room, every 15 minutes, midwives have to go to monitor the fetal heart sounds, then make the vaginal examination and everything.
to give birth vaginally, it would take 6 to 8 h. For a caesarean, it is 45 min and then finished!
Role of the policy of access to free caesarean section procedures in the overuse of caesarean section
And I told you last time, and I’ll tell you again, I still have a little fear, not a little, a big one! Because I believe in 5–10 years, all the uteruses will be scarred, and you see, all the consequences, the complications… The people only perform but do not think! And they do not see the consequences! Placenta accreta, all these factors contribute to maternal deaths. (…) It increases quickly! It goes up fast! And it's a fashion! It's a fashion.
this can be considered as a high rate, which has increased over time. Four or five years ago, the rate was approximately 25%, and now, this hospital is at 44%. But when I think about it, I have an explanation because we are a maternity school, so there are learners, and the indications are not always well thought out before decisions are made, so there are indications for caesarean section that are new indications that we have never seen before! (...) Yes [there are excessive caesarean sections], of course. More than excessive, abusive! (....) Well, in theory [the policy of free access cannot increase the number of abusive caesarean sections], but in reality, yes.
Doctors are less rigorous now in terms of caesarean section because, for hospitals, it is a source of money, so doctors are more inclined to do caesareans more easily (...) For hospitals, when the state pays the costs of caesarean section, it's a breath of fresh air for them; so today, indications for caesarean section are for nothing.
I would like to add that I am very affected by seeing that we are moving toward the limits of certain policies, such as access to free caesarean sections. Even if we have not been able to evaluate the contribution of free caesarean sections to the increase in the rate of caesarean section, we can still understand that we must try to limit its use. Of course, it's free, but on the other hand, you have to see the dangers it can bring. The societal implications are enormous.
when it was announced that caesarean section would be free, many women started asking for caesarean section because, when women are suffering, they ask for caesarean section, as well as because caesarean sections are free. Do you understand why? Because it's free, they say, ‘Do a caesarean on me’, anyway, it's free. We say, ‘No, we do not do caesarean sections that way; we do caesarean because we need a medical indication. It's not because it's free that you'll get up and say, ‘Do a caesarean section on me’. More and more it has been like this.
I think that this free policy allows us to get closer to a normal rate (...) It seems that the rate has increased with the free policy; it brings us closer to where we should be. Of course, it favours abuse (...) Maybe we are above where we should be and below where we should be.
In Mali, we do not have enough caesarean sections. So don’t start searching for non-medically-justified caesarean sections (Bamako, field notes, January 2017).
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