Nigeria has one of the world’s highest maternal mortality rates. One reason? Patients often decline C-sections, even when it could save lives. These women are trying to change that.

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When Alice Ogbara recently divulged the details of her Caesarean section to a group of women, it wasn’t an ordinary “birth story” casually shared amongst friends: she was doing something that many would consider risky. That’s because she was talking about a surgery that some women would refuse to go through with, never mind talk about, even if they knew it could save their lives.

“When I walked myself [into the operating theatre], I saw everything they were going to use on me, and I was crying,” Ogbara told the others. She said she was scared she would be damaged irreparably. Then a sheet was put over her belly. “The next thing I heard was my baby crying,” she recalled – prompting congratulatory applause from the women surrounding her.

Beyond this courtyard in Lagos, Nigeria, Ogbara might not share her story so willingly. Concerns over the safety of the surgery, combined with religious and social factors, mean that C-sections are stigmatised in Nigeria. This causes many women to resist the surgery – or hide it when they do go through with it. Ogbara even kept her C-section secret from members of her family. “If you tell us Nigerians that you are going to go through Caesarean section, they will tell you: ‘God forbid’,” Ogbara says.

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The meeting she attended was run by a Nigerian non-profit called Mamalette, which supports pregnant women and is trying to bring down maternal mortality rates across Lagos. Part of that effort involves tackling the stigmas around birth that intercept women’s access to lifesaving care.

Across Nigeria, 58,000 women die in childbirth every year, giving the country the world’s fourth-highest maternal mortality rate. Part of the problem is the country’s low Caesarean rate: just 2%. The global rate is 21%.Meanwhile, there’s just one doctor for every 6,000 people in the country.

Mamalette aims to provide for women what under-resourced healthcare workers often cannot: supportive health education, and a sympathetic ear for their concerns. Their grassroots approach is showing early success in improving health outcomes for pregnant women. But the small organisation is up against considerable challenges.

Global disparity

In the global context where C-section rates are rising rapidly, Nigeria’s numbers stand out. Between 2000 and 2015, C-section rates almost doubled across the world. In countries like the Dominican Republic, women now undergo the surgery in more than 50% of cases. In North America, it’s 32.6%; in the United Kingdom, 26.2%.

In West Africa, an average of just 4.1% of births involve a C-section, and Nigeria’s rate is half that.

To effectively prevent maternal mortality, a country’s Caesarean rate shouldn’t be below 5%, the World Health Organisation says. That’s because medical C-sections are essential for preventing obstructed labour in cases where a woman’s pelvis is too small, the baby is in a breech position, or is too large to exit the birth canal. Without intervention, a constricted baby may fatally rupture the uterus, or cause tears that catastrophically haemorrhage.

“I think it’s the indicator in health with the greatest possible disparity of overuse and underuse,” says Carine Ronsmans, an epidemiologist at the London School of Hygiene and Tropical Medicine and an author on recent reports detailing the global Caesarean increase.

A very high number of C-sections can be concerning because Caesareans can increase the risk of conditions like placenta previa, which can cause severe bleeding. At the same time, “so many women still die from not having access”, Ronsmans says. “We really can't afford to forget these women.”

In Nigeria the obstacles to access are especially high in rural areas, where roughly 58% of deliveries take place with unskilled birth attendants.

In urban centres with more hospitals, cost and stigma are the primary barriers. Stigma is driven by notions that vaginal birth is aligned with womanhood, whereas C-sections are not – a common idea in countries like the UK, too.

That’s fortified by religion in Nigeria: Christian women commonly hear that giving birth vaginally like a “Hebrew woman” is a sign of strength and competency. This originates from a passage in the Bible, which tells the story of “vigorous” Hebrew women who stoically give birth unattended by midwives.

That mythic ability to give birth vaginally – and unattended – has been upheld as a symbol of maternal virtue in Nigeria. “Nigeria is a deeply religious country, and everything is very spiritualised,” says Adepeju Jaiyeoba, founder of Nigeria’s Brown Button Foundation which is  working to reduce maternal deaths.

Hospitals routinely encounter women who – scared of shaming their families – simply refuse the surgery. Often women have limited control over their own births: one case study of a Nigerian hospital revealed that in 90% of cases, women believed men should be the ones to sign the consent form enabling them to undergo C-section – placing the decision firmly in male hands.

In other countries like the United Kingdom and the United States, the situation may not be as extreme. But women still face stigma for having Caesareans.

And high-quality obstetric care doesn’t necessarily translate to perfect conditions for pregnant women. In 2018, maternal rights charity Birthrights found that almost three-quarters of public hospitals in the UK don’t have a clear policy allowing women to request planned Caesareans, which contravenes national clinical guidelines. Birthrights believes that has a stigmatising effect  –  especially when women have specific reasons for avoiding vaginal birth, such as a history of sexual assault, or mental health issues, says Amy Gibbs, Birthright’s chief executive.

“Women should be the primary decision-makers at birth. That right to choose what will happen to your body is so fundamental.”

That principle is what Mamalette is fighting for in Nigeria, too.

Health advocates

Just off a chaotic street where three-wheeled keke taxis and motorbikes weave through gridlocked traffic, Anike Lawal sits inside Mamalette’s quiet, cool office in the tech hub that is Lagos’s Yaba neighbourhood.

A thoughtful, softly spoken woman, she says she launched Mamalette as an online community where mothers could support one another. “I didn't set out to try to save anybody’s life,” Lawal says. But tapping into the widespread community of women showed her how much risk even urban mothers faced in childbirth. “When people talk about maternal loss, you never think of women who live in cities, women who have smartphones and Facebook,” she says.

In 2017 Lawal started recruiting mothers to help local women in their communities safely through pregnancy. That evolved into today’s 20-member strong team that Lawal calls the “Mamalette Champions”.

These mentors, who receive training from midwives, nurses, and doctors, currently work in 20 urban-poor communities across Lagos and one in the city of Ibadan, serving more than 300 people through one-on-one home visits. They ensure that women attend their antenatal classes and register at hospitals to give birth instead of using traditional birth attendants. Often, they attend hospital with women when they go into labour. “In a country when we don't have enough hospitals or doctors, preventive care is very important. That’s what we’re doing,” says Lawal.

Uniquely, Mamalette also creates a safe space where women can talk about taboo subjects around birth, like Caesareans. Often, in the communities they serve, they’re the first port of call for women who want to discuss these concerns – ranging from stigmas to the quality of surgical care, which can be low in some facilities.

“Mamalette is like an intermediary between the healthcare system and the people,” says Blessing Kolade, a former mentor who now works on the programmes team at Mamalette. “The healthcare system is so overwhelmed that even the healthcare workers do not have the time to break down the information. Women cannot open up; they can’t ask any questions,” she says.

That means misconceptions slip through and stigmas go unchallenged. Many women who need a C-section contemplate it for the first time when they already are in labour. At that point they’re less likely to accept the surgery, because they’re grappling with entrenched beliefs that they’ll bring their families shame. “Because of that stigma you will see somebody who’s at the point of death and still refusing a Caesarean section, because she doesn’t want to go through all that,” says mentor Oluchi Anumni.

Mamalette tries to address these problems before they get to this fateful stage. Mentors, who are specially trained to debunk misconceptions around C-sections, clearly outline the reasons why women may need a C-section, such as having a small pelvis, or medical conditions like preeclampsia. This takes the shame out of the equation, and provides women with facts that give them ammunition against the judgement they might receive.

Some mentors even end up defending their mentees’ decisions in hospital. “We’ve had champions who have advocated for pregnant women with their families if they needed to have medical procedures done,” says Lawal.

Anecdotally, the women have noticed that their group members are much more receptive to Caesareans. Mentor Adenike Lasisi-Opaleye says she invites women who have had C-sections to come and show mentees their abdominal scars to dispel the myths about what C-sections really do. “Their perception was that C-sections were a no-go. They are now informed that [it’s] not a death warrant,” Lasisi-Opaleye says. The data Mamalette collects also shows that the majority of women under their care are now giving birth in health facilities, according to Lawal.

“I can proudly say that so many women have escaped death through the things they have learned,” Anumni adds.

Complex solutions

But when it comes to maternal health, simply tackling cultural and social barriers to C-sections isn’t enough. 

Recent research revealed that across sub-Saharan Africa, C-sections are up to 50 times more fatal than in high-income countries. That mainly stems from untreated haemorrhaging and botched anaesthesia, says Salome Maswime, an obstetrician, gynaecologist and lecturer at University of the Witwatersrand, who was involved in the research.

“As a doctor, I really feel access is the place to start. But I’m nervous to simply say access on its own,” Maswime says. “We need to pay attention to the quality of surgical care that women have.”

She believes that if care improves, it would also lessen stigmas associated with the surgery: “I don’t think it’s as simple as counselling women,” Maswime says. “It’s a complex problem requiring complex solutions.”

The cost of medical care is also a deterrent to obtaining surgery in Nigeria. Some countries have tried to improve access by making C-sections free. In Mali and Benin, removing user fees has been shown to increase hospital births and to lead to better health outcomes for women and their infants. In Nigeria similar changes are unfolding: the Lagos State government, for example, recently announced the launch of a new health insurance scheme that will make Caesareans free.

Also in Lagos State, some hospitals now refer women who refuse C-sections 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 lending women a sympathetic ear is a powerful approach. “What we really need to be doing is trying to bring the women along as partners,” he says.

In the UK, a similar “partnering” approach is helping hospitals increase women’s access to planned C-sections. Instead of banning planned C-sections outright – as Birthrights discovered was strikingly common, occurring in 15% of hospitals – some facilities now say that if women have been presented with the information they need to make an informed choice, their decision to have a planned C-section will be respected.

That has soothed relations between patients who may previously have felt stigmatised or anxious about the lack of control over their births, and doctors who felt forced to override women’s concerns, says Nina Johns, an obstetrician at Birmingham Women’s Hospital which has adopted this new approach. “It provides that opportunity to work together, rather than antagonistically.”

Whether it’s Nigeria or the UK, the fundamental problem and solution is the same, says Birthright’s Amy Gibb. “Often the woman’s right to choose what happens to her gets lost,” she says. “The way to get this right is to put women at the centre of choices about their care.”

A legacy of change

Mamalette recognises the task they face is too big for one small organisation working in just a sprinkling of communities. But they believe that by empowering women with information, they’re also bringing about a longer-lasting kind of change.

“Something that Mamalette is doing that we have not really seen is it’s giving women identity,” says former Mamalette mentor Olamide Ekpenyong. “We are trying to let women know that you have to stand and be bold. Don’t let society define you.”

Encouraging women to assert their rights to lifesaving care crystallises that goal. “With that knowledge they educate others,” says another mentor, Christiana Ogunbowale. “Some of them have girl children, so Mamalette is already preparing the future for the women upcoming.”

Alice Ogbara says her own outlook has changed. Now her daughter is a year old, and Ogbara is no longer so cautious about telling people how she gave birth.

“I tell people around me, I share my own experience with them,” she says. She’s careful – advising women that if they need to have a C-section that they only should go to trusted hospitals, for example. But she’s also encouraging. “A C-section is not a bad thing,” she tells people. “It’s just a second way of delivering.”

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The reporting for this article was made possible with funding from the European Journalism Centre’s Innovation in Development Reporting Grant programme.

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