By Culton Scovia Nakamya
In 2021, Esther Nakajugo (not real name) a top manager at one of the education institutions in the country, was two weeks away for her exams in public administration and management at Uganda Management Institute.
At the same time, Nakajugo was due for delivery in the same period. She took a bold decision and asked her gynecologists at Nsambya Hospital to opt for cesarean section to avoid collusion with her examination time table. Upon examination, this was done, one week away.
“I weighed in and realized it’s the only option I had. It’s hard to be a mother and at the same time a student. My worry was missing exams and then prolonging my graduation period. Both academics and motherhood were demanding, but at least I managed to succeed,” relates Nakajugo.
Nakajugo had one week of nursing the baby and the cesarean wounds and later, happily walked the examination room. She would go with her baby and leave her in the car parking with a nanny as she wrote her papers.
“It was quite discomforting. If I knew what it takes, I should’ve made a different decision. My concentration span was low. I kept thinking about my baby, whether she is safe, crying and lots of other things. The cesarean wounds were discomforting. You have to be extra careful not to hurt yourself”. She narrates.
Joselyne Nalujja a senior midwife at Jinja regional referral hospital says there is an increase in elective cesarean delivery. Elective cesarean is a delivery option upon the request of the expectant mother. Elective means it is planned before the mother goes into labor.
The practice is most common in western countries. In Australia for example, according to the Australian department of health and aged care, 3 out of every 5 births are elective.
Reports from different major facilities indicate that the practice is steadily growing in Uganda, especially from working class women and students.
The annual health sector performance report 2020/21, indicates an increase in health facility deliveries, from 62% in 2019/20 to 64% in 2020/21 financial years.
This increase does not leave out an increase in cesarean deliveries. Whereas the health sector report does not clearly state the ratio of normal and cesarean deliveries, it notes an increment in the delivery services especially at health centre IV facilities.
According to the report, Rwekubo health centre IV in Isingiro registered the highest number of cesarean deliveries with 1,555. St. Paul Health Centre IV Kasese followed with 1,450, Kyangwali HCIV in Kikuube with 947, Midigo HCIV in Yumbe registered 886.
In Kampala, Kisenyi Health Centre IV registered 885 and Kawaala had 781.
Ordinarily, cesarean deliveries are done from the 39th week of pregnancy onwards, many times after a recommendation of a midwife or gynecologist upon examination and conclusion that the expectant mother might not achieve a safe normal delivery.
Some underlying causes include high blood pressure, diabetes, HIV, fibroids, placenta preavia, abnormal position of the baby (breech position or feet first) and the midwife fails in positioning them rightly. Other underlying medical conditions are infections that can be passed onto the baby among others. Cesarean deliveries are aimed at saving both the lives of the mother and the baby.
Nalujja says the option is risky due to anesthetic complications no wonder, all mothers who opt for elective delivery are counseled before approval.
“We always tell them this is not the best mode of delivery because there are no underlying factors. But because they have a right to participate in decision making of medical care, they deserve a chance to be listened to and that why their choices get approval”. Says Nalujja.
Emmanuel Ssendikwanawa a medical researcher says the risk of getting complications with elective delivery is higher and some of them can lead to death like hemorrhage.
Reports from the ministry of health indicate that Hemorrhage is the leading cause of death among women in Uganda at 42%. It is a condition where the mother bleeds to death due to delivery complications. Some are normal while others are due to cesarean complications.
Ssendikwanawa says the period of recovery for normal delivery is much quicker and safer than cesarean, urging women to accept and revise their decisions until doctors advise otherwise.
“So many infections can be avoided with normal delivery. It might give them convenience now but it’s risky at a later stage. Women need to let cesarean deliveries happen only if the doctor or midwife says so,” he said.
Reports from the ministry of health indicate that maternal mortality increased at higher levels of care than lower facilities in the 2021/2022 financial year.
The annual health sector performance report further indicates that Uganda registered 1,226 maternal deaths, which translates into 85/100,000 live births.
Referrals and large private but not for profit facilities recorded 566 cases (46%), General hospitals registered 387 deaths (32%), Health Centre IV’s recorded 183 (15%), Health Centre III’s 61(5%), and health Centre II’s 26 (2%).
927 deaths were reviewed and 42% were attributed to hemorrhage (excessive bleeding both during normal and cesarean deliveries), 15% were due to hypertension and 13% were not assigned a cause.
