Abstract
Taboos about birthing choices mean thousands of women and babies in Nigeria die unnecessarily.
One of the reasons for the high rates of maternal and infant death here is the taboo surrounding birth. Caesarean section rates are very low because of the stigma attached to not having a natural birth. It is also a society which does not talk about the dangers of giving birth, and still isn’t investing enough money in high-quality maternity services.
C-sections, if performed properly in clean hospitals, are a way to drive down maternal mortality. A rate of 10% or higher is needed to start having an effect, but a major study published in The Lancet in 2018 found that in west and central African regions, C-sections were used in only 4.1% of births.
For most Nigerian women, marriage is a prerequisite, and having children is a rite of passage. When you are unable to give birth conventionally, it can be seen as an indictment on your womanhood, often provoking the labels “weak” and “lazy”.
Many women who require C-sections during childbirth will look for hospitals or midwives, or even those who are untrained, to assist with vaginal deliveries, regardless of the risk posed to their lives and that of their unborn babies.
Abosede Lewu, an obstetrician and gynaecologist at the Lagos University Teaching Hospital, said: “In our environment, having a C-section is still seen as a form of weakness due to the combination of religion and culture. In certain cultures, if you shout during a normal delivery, you are seen as a weak woman. So the fact that you cannot do it quietly makes you a sort of failure. You can imagine with people like that, a C-section is not even an option because for you to even scream in labour, you have already dropped the baton.”
Nigeria is still ranked as the country in sub-Saharan Africa with the highest rate of maternal deaths, and makes up 14% of the global maternal mortality rate. According to a Unicef report, one woman dies every 10 minutes on account of pregnancy or childbirth in Nigeria - a total of 53,000 women per year.
This parlous state of affairs was in the global spotlight in 2018 when Gates gave a speech at the National Economic Council meeting on Human Capital Investment in Abuja condemning the high infant and maternal mortality in the country. Women’s representation and women’s health is being highlighted by commentators as an urgent issue for the presidential elections in February 2019.
Lewu, who also runs Girls-Aid, an initiative that focuses on the wellbeing of women and girls by giving them access to health and life skills, believes that the pressure and stigma sometimes come from those closest to the mother-to-be. “There is also some kind of female bullying or peer pressure where your friends that delivered on their own sort of snigger when you have a C-section. Or a mother-in-law, or even a mother, to a daughter saying ‘You are just lazy, you could have pushed’.”
A mother with her infant twins in a Nigerian makeshift maternity ward
CREDIT: Nichole Sobecki/AFP/Getty Images
Religion is a large part of the Nigerian cultural identity, so at gatherings, weddings and even ante-natal classes it isn’t out of place to hear prayers admonishing C-sections for new brides or mothers to be.
Lewu explains that this is one of the reasons women who have C-sections hide, often giving false testimonies in church about natural deliveries.
“I have a couple of friends who have had C-sections and you ask them and they still tell you that they had a vaginal delivery. It is easier for educated women who have come to terms with C-sections, but the people who contribute to maternal mortalities are the not-so-educated people,” she said.
This is not just about women’s choices, though. It is about a whole society which is not prepared to talk about this issue or invest properly in women’s maternity services, so women are left to die because of secrecy surrounding childbirth – not only in the countryside and villages but also in cities such as Lagos.
Nigerian lifestyle vlogger Sisi Yemi vividly remembers her own birth experience three years ago, where the women around her were unwilling to share their experiences, leaving her both anxious and confused.
“Even when you ask ‘How was it for you?’ they don’t tell you they did the C-section, they don’t tell you anything,” she said. “Nobody ever talks. When I asked my friends and the people that had given birth around me, all they said was ‘You will go and do your own and you will find out’.”
But thanks to YouTube videos and online pregnancy apps, her anxiety didn’t tip over the edge. “They tell you everything,” she said. “That was where I was getting all my information from, because people around me wouldn’t talk about pregnancy. Even my mother said ‘Go there and experience it’.”
C-sections also have a heavier cost implication, and with many Nigerians having a deep distrust of the healthcare system, there is a general belief that hospitals prioritise their bank balances over women’s lives.
For Sisi Yemi, even her healthcare providers were giving less than satisfactory information, and being constantly met with a wall of silence from other women left her caught between a rock and a hard place, not knowing where to go.
“That lack of information went all the way to the end, till the delivery,” she said. “They don’t offer the information, so if you don’t know what you are asking for, you don’t get the answer. They said they were going to induce me and I remember I saw something brief online about induction and I asked: ‘What is this induction, is it an injection, will it be painful?’. All I was getting was typical Nigerian answers like ‘don’t worry’. There was no answer, really, about what the procedure was. I just knew I was going to be induced.”
Women are silenced and it affects their ability to share, seek information and make informed choices about their bodies and their healthcare.
Lewu recalls a tragic incident of a woman who was booked for a C-section during her second pregnancy. Her husband – insistent that she have the baby on her own – moved her to another hospital where she ended up in labour for two days before the baby died and she needed surgery to have it taken out. She ruptured her bladder and developed infections, leading to three more surgeries and a hysterectomy.
“She was 31 and she had no baby,” said Lewu. “Those are the extreme end of people that don’t want a C-section.”
Stigma in Nigeria is fatal. Women and society in general are not talking enough about the scandal of so many women dying in childbirth. There are many stories that range from ruptures and post-partum bleeding to deaths on a daily basis.
For Lewu, what matters is that mothers and babies survive, and this needs to trump all societal and religious dogma.