As medical doctors resort to caesarean section to prevent mother-to-child transmission
The joy of every woman is to deliver her baby normally. This is in spite of the much travail associated with pregnancy and delivery. Before now, the most available or preferred option for most women is natural birth. As the world recorded countless maternal deaths due to this process, scientists sought an alternative and came up with the Caesarean Section, CS. With the prevalence of the Human Immunodeficiency Virus (HIV), however, and for the avoidance of Mother-To-Child-Transmission (MTCT); medical doctors and most hospitals have resorted to this ‘safe’ practice in child delivery. In this report, BENJAMIN OMOIKE takes a deeper look at the matter and the serious challenges posed by the dreaded disease, which has become a pandemic.
Today, many babies have been delivered successfully through cesarean section. But this success story is not without criticisms. In fact, this life-saving option has become a subject of controversy. How be it, a good number of women now claim CS is now an option explored by doctors to extort huge delivery bills. For women who are infected with HIV, the question on their lips is, ‘is it not possible for them to have normal deliveries?’
So, the question is, can HIV infected mums have normal deliveries without infecting their unborn kids? According to Doctor Mohammed Sha’ibu of the Ahmadu Bello University Teaching Hospital (ABUTH), “Yes it is possible, but rare. With modern supervised pregnancy and care, it is possible. It is possible to have a vaginal delivery if there are no other complications associated with the pregnancy and if the viral load is low.”
Also acknowledging the fears expressed by some of the infected women, he said: “The fears of the women are real because it is safer to have your baby naturally than a C-section, especially in a country where the infrastructure is not controlled. Maternal mortality is very high in Nigeria and there are many reasons for that and one of the reasons is that we don’t have clear bench marks for the facilities that provide emergency obstetric care.
“There should be a clear bench mark which says before you can deliver a baby in this facility you must have this kind of infrastructure in place. So if we have that kind of infrastructure in place, I think we would allay the anxiety of some of these women. Anybody can have a room and say I am doing a CS. Until we have that kind of control we will continue to lose women. Having said that, it is safer for an infected mother to have a CS so as to forestall any chance of infecting her unborn baby as is possible during vaginal delivery. This is not to say vaginal delivery is not possible,” he explained.
In the same vein, a surgeon with the Lagos State University Teaching Hospital, LASUTH, Dr. Olugbenga Saliu Oseni, described CS as an interventional delivery process, whereby you have complicated delivery. According to him, it is sometimes the only option left to save the life of mother and child. On situations that could warrant CS, he said: “The best thing to happen to a woman is to have a normal delivery but when this is not available, the preferred option should be CS because you can evaluate your result.”
According to him: “There are many reasons why a doctor should prescribe CS and some occur in critical situations. Others are used to prevent critical situations and some are elective. CS can occur when placenta lies low in the uterus and partially or completely covers the cervix. One in every 200 pregnant women will experience placenta previa during their third trimester.
“Again, placenta abruption could also cause a doctor to prescribe CS. It is the separation of the placenta from the uterine lining that usually occurs in the third trimester. Approximately one per cent of all pregnant women will experience placenta abruption. In approximately one in every 1,500 births, the uterus tears during pregnancy or labour.
“This can lead to haemorrhaging in the mother and interfere with the baby’s oxygen supply. This is a reason for immediate cesarean. The position of the baby could also lead to CS. When dealing with a breech baby, a caesarean delivery is often the only option, although a vaginal delivery can be done under certain circumstances. Also, cord pro lapse is another cause; it occurs when the umbilical cord slips through the cervix and protrudes from the vagina before the baby is born. When the uterus contracts, it causes pressure on the umbilical cord which diminishes the blood flow to the baby. Sometimes, we do have women who are small in stature or are in the border line. It is obvious such women can go through normal delivery,” he emphasised.
“Another reason is fetal distress. If fetal monitoring detects a problem with the amount of oxygen that the baby is receiving, then an emergency cesarean may be performed; failure to progress in labour: this can occur when the cervix has not dilated completely, labour has slowed down or stopped, or the baby is not in an optimal delivery position.
“Ninety per cent of women who have had a cesarean are candidates for a vaginal birth after cesarean for their next birth. Cephalo pelvic disproportion, active genital herpes, diabetes increase chances of cesarean as well as pre-eclampsia, that is high blood pressure in pregnancy, birth defects and multiple births amongst others,” he added.
“CS is an emergency when you did not expect it and you need to intervene urgently. It is elective when you know that the baby must come through CS. For instance, an elderly person who has suffered infertility for a long time and is having a baby for the first time; we call such babies ‘precious baby’ and we don’t want anything to happen to them. So you want to electively deliver them by CS.
Dismissing beliefs that doctors are recommending CS in order to make more money from patients, Oseni said: “It will be crazy for any doctor to think he wants to do a CS because he wants to make more money; that means that person is not an expert. I know that when I want to do surgery I lose appetite. You can still collect the same amount for CS for normal delivery because there are some normal deliveries that are even worse than CS. So that is an idea people do have in their heads.
“Elective CS is safer than emergency CS because everything is okay when you do elective. But in case of emergency, the patient may have some other abnormalities like hypertension or pre-eclampsia. Sometimes, we deliver them if they are progressing well. Hardly will one die because of an operation. Death arises from either the patient or relatives.”
He explained that from experience many of the patients who were advised to have CS and they refused and ran away from the hospital usually came back to the hospital with more complicated cases such as inability to conceive again, loss of child, amongst others. Oseni argued that studies have shown that some babies delivered by Cesarean Section have a better IQ because they did not go through the stress of delivery.
The scourge of HIV/AIDS is a serious problem that cannot be overemphasised. Half of all HIV infections occur in women in Africa. Young women are particularly at risk and they are the child-bearing population. About 90 per cent of MTCT infections occur in Africa. MTCT of HIV can occur at any stage of pregnancy. A survey of women attending the HIV Clinic in the Lagos University Teaching Hospital, Idi-Araba (LUTH) was carried out and it was found out that a lot of infected mothers still did not have adequate knowledge of the disease.
HIV transmission from mother to child can occur during pregnancy, labour and delivery, or breast feeding and this is called perinatal transmission. Research published in 1994 showed that zidovudine (ZDV) given to pregnant women infected with HIV and their newborns reduced the risk for this type of HIV transmission. Since then, the testing of pregnant women and treatment for those who are infected have resulted in a dramatic decline in the number of children perinatally infected with HIV.
However, much work remains to be done about the virus. A large number of children are still infected annually. Many of these infections involve women who were not tested early enough in pregnancy or who did not receive prevention services. Perinatal HIV transmission is the most common route of HIV infection in children.
The question then is, is Mother-to-Child HIV Transmission Preventable?
According to Doctor Samuel Adegbite, a Gynaecologist in a private hospital in Lagos, “mother-to-child transmission (MTCT) of HIV, also called perinatal or vertical transmission, occurs when HIV is spread from an HIV infected woman to her baby during pregnancy, labour and delivery or breastfeeding. For an HIV woman not being treated for HIV, the chances of passing the virus to her child is about 25 per cent during pregnancy, labour and delivery. If she breastfeeds her infant, there is an additional 12 per cent chance of transmission.
“Worldwide in 2001, 1.8 million women became infected with HIV. Approximately 800,000 children also became HIV infected, the majority of them via MTCT. A large proportion of people newly diagnosed with HIV worldwide are between 15-24 years old. A very important component of MTCT prevention must be HIV prevention for young people, especially girls and young women before they become sexually active, and treatment for those already infected,” he explained.
Are all women equally at risk for MTCT?
“No. More than 95 per cent of HIV infected women in the world live in developing countries and most HIV infected children are born in developing countries. Global societal and economic inequities create a wide gap between women in developing nations and women in developed nations with regard to HIV prevention, voluntary counselling and testing and access to drugs which treat HIV infection and can prevent MTCT.”
Can MTCT be reduced?
“Yes. Advances in treatment and new classes of drugs have provided the opportunity to greatly reduce rates of MTCT worldwide. However, these advances have not made their way to developing countries to the extent that is needed, and we have still not addressed the root cause of MTCT, mainly heterosexual HIV transmission. The best way to prevent MTCT is to prevent HIV transmission in the mother and father.
“In order to reduce MTCT, all pregnant women should have access to free or low-cost prenatal care and voluntary HIV testing and counselling. If a pregnant woman is HIV+, she should have access to antiretroviral treatment both to treat HIV and improve her own health, and to decrease the chances of HIV infection in her infant. Treatment options for preventing MTCT include giving antiretroviral drugs to the mother after the first trimester of pregnancy and during labor, and to her infant for the first six weeks of life. In the US, these drug regimens have dramatically reduced the chance of transmission, from about 25 per cent to 4 to 10 per cent for women who did not breastfeed.
“MTCT can be further reduced to less than two per cent if a woman is on antiretroviral drugs, has a low viral load, follows the recommended MTCT treatment regimen and does not breastfeed. However, little is known about the long term impact of these drugs on the child. Taking greater care during labor and delivery can also help reduce MTCT, for example not artificially rupturing membranes or doing routine episiotomies, and providing cesarean delivery when indicated,” he says.
What are the HIV risks of pregnancy and childbirth?
“An HIV-positive mother who is not being treated for her HIV during pregnancy, labour, or delivery has a 25 per cent chance (1 in 4) of passing the virus to her baby. However, there is good news. There are antiretroviral drugs that can protect babies from HIV infection.
“When an HIV-positive mother receives antiretroviral drugs during pregnancy, labour, and delivery; has her baby by Cesarian section; and avoids breastfeeding, the chance of passing the infection to her baby falls to less than 2 per cent (fewer than 2 in 100). The newborn babies are also given treatment after birth to protect them.”Of course, some women do not find out they are HIV-positive until they are already in labour. But there are still treatment options that can help protect their babies. If they receive antiretroviral drugs during labour and delivery and avoid breastfeeding, the chance of passing the infection to the baby can still be significantly decreased,” he says.
“Imagine a world where no mother living with HIV will have to transmit the virus to her baby while giving birth. Just 10 years ago, this would have been considered an impossible goal. But, thankfully, with the incredible advances in HIV/AIDS treatment, prevention of mother-to-child transmission is real today and is helping the world take giant steps towards achieving an AIDS Free Generation. But still, 900 babies are born every day with HIV,” he concluded.
Meanwhile, former Director-General of the National Agency for the Control of Aids (NACA), Professor John Idoko, has revealed that Nigeria carries the second largest burden of Human Immuno Virus (HIV) globally, adding that 3.4million Nigerians are now living with the disease. This was as the President of the Senate, Senator David Mark, called for an end to stigmatisation and discrimination against persons infected by the dreaded disease in the country.
The duo had made the assertion some years ago at a public hearing organised by the Senate on a “Bill for an Act to make provision for the prevention of HIV discrimination and to protect the human rights and dignity of people living with HIV and affected by Acquired Immune Deficiency Syndrome (AIDS) and other related matters.”
Professor Idoko stated that while the national prevalence had stabilised around four per cent, 13 states still carry higher burden, adding that the country was behind target in several important indicators. He said one out of every three people was currently receiving treatment, adding that only 18 per cent of HIV positive women receive prophylaxis, a treatment to prevent mother-child transmission of the disease.
He also revealed that only 18 per cent of the population has been tested, while more than 40 per cent of HIV positive persons do not know their status, noting that, “Most successful initiatives recognise the role of legislation as tool against stigma and discrimination.” The NACA DG however expressed optimism that the Bill, when passed into an Act, would strengthen legal protection for vulnerable groups and ensure greater access to prevention, treatment and care services.
In Nigeria, the HIV prevalence rate among adults ages 15 to 49 is 0.9 per cent. Nigeria at a point, had the second-largest number of people living with HIV. The HIV epidemic in Nigeria is complex and varies widely by region. In some states, the epidemic is more concentrated and driven by high-risk behaviors, while other states have more generalised epidemics that are sustained primarily by multiple sexual partnerships in the general population.
Youth and young adults in Nigeria are particularly vulnerable to HIV, with young women at higher risk than young men. There are many risk factors that contribute to the spread of HIV, including prostitution, high-risk practices among itinerant workers, high prevalence of sexually transmitted infections (STI), clandestine high-risk heterosexual and homosexual practices, international trafficking of women, and irregular blood screening.
Nigeria is emerging from a period of military rule that accounted for almost 28 of the 47 years since independence in 1960.
Consequently, the policy environment is not fully democratised. Civil society was weak during the military era, and its role in advocacy and lobbying remains weak. The size of the population and the nation pose logistical and political challenges particularly due to the political determination of the Nigerian Government to achieve health care equity across geopolitical zones.
The necessity to coordinate programs simultaneously at the federal, state and local levels introduces complexity into planning. The large private sector is largely unregulated and, more importantly, has no formal connection to the public health system where most HIV interventions are delivered. Training and human resource development is severely limited in all sectors and will hamper program implementation at all levels. Care and support is limited because existing staff are overstretched and most have insufficient training in key technical areas to provide complete HIV services.
First case of HIV/AIDS in Nigeria was reported in 1986. In 2010, HIV prevalence is highest in urban areas, the North Central zone, Benue State and among the 30 to 34 years age group. HIV prevalence among youth age 15 to 24 declined from 6 per cent in 2001 to 4.3 per cent in 2005, 4.2 per cent in 2008 and 4.1 per cent in 2010. More than 80 per cent of HIV transmission in Nigeria is through heterosexual sex. Among key populations at higher risk, HIV prevalence is 24 per cent among sex workers; 17 per cent among MSM and four per cent among IDUs respectively (IBBSS 2010). The drivers of the epidemic in Nigeria include high illiteracy, high rates of Sexually Transmitted Infections (STIs) in vulnerable groups, poverty, low condom use and general lack of perceived personal risks.
Rolake Odetoyinbo undoubtedly has one of the most powerful voices as far HIV/AIDS is concerned in Nigeria. Her values, her story- especially her triumph over AIDS-related stigmatisation remains a great source of inspiration for many women living with HIV in Nigeria. And so, when in 2006 Rolake was delivered of a gorgeous baby boy; Eyilayomi, it was a huge story with immense potentials. Rolake, then a columnist with Thisday Newspaper, couldn’t wait to share the story herself with her readers. The story, as it turned out dealt AIDS-related stigmatisation a further blow.
Her story also demystified the science of helping HIV-positive mothers give birth to healthy HIV-negative babies while providing a basis to evaluate the quality of Prevention of Mother-To-Child Transmission (PMTCT) Services in the country. Soon after Eyilayomi’s birth, several other young, HIV-positive mothers have recorded similar successes and currently coping with the challenges of motherhood and living life as HIV-positive mothers.
“To be sincere, I’m denying my baby the best of time. Most times I’m not always there for him and I feel bad as a mother. It has not been easy, but thank God for my partner; he has been so supportive”, says Monisola Ajiboye who until now was an active member of the Network of People Living with HIV/AIDS (NEPWHAN) Lagos Chapter.
The joy of being a mother is one most women wish to share. But for a woman living with HIV, it can be a different ball game for a person living with HIV. “The concerns even begin while you are pregnant; you are worried about your unborn child becoming HIV-positive and how he would cope if he turns out HIV-positive.” For Moni, there are even more concerns and this also cuts across most HIV-positive women and that has to do with choosing between breast feeding and not breast feeding.
“My in-laws were anxious to know why I am not breastfeeding. It took time for them to understand why I didn’t and that is because AIDS-related stigmatisation is still on the high side and you get to feel it more as a mother living with HIV.”
Stigma threatens the quality of PMTCT services and even expose children born HIV negative to infection as most mothers for fear of disclosing their HIV positive status to in-laws often breast feed their babies and risk getting them infected. Moni believes the problem is one that can only be dealt with within our national AIDS response.
“Stigma can be a personal issue it can also be an issue you need to deal with on the policy level where laws are made and enforced against stigmatization, but the major step begins with how the HIV positive woman see herself. If you are having issues accepting yourself as someone living with HIV, no law, no matter how effective can help you.”
Bose Olotu, AIDS activist, HIV-positive mother and counsellor feels ignorance and lack of appropriate information are the major barriers especially when there are so many healthy, HIV-free babies born to HIV-positive mothers, yet there are growing numbers of HIV-infected children at pediatric wards.
“It is so sad that we still have children being infected by HIV virus these days and what I feel could be fueling this is lack of appropriate knowledge about the virus; lots of people are aware of this disease but few have the correct information”, says Olotu.
According to Olotu, correct information in this regard has to do with knowing all there is to know about breastfeeding as a mother living with HIV and choosing between to breastfeed or not to breastfeed and having what it takes to live with the implication of both choices. “If we can do it, every other woman can if only we can expand access to free quality PMTCT services to them.
“Most mothers want to breastfeed. But quality information on breast feeding are not been passed on to these women and so many of them are happy that they are not going to give their babies infant formulas. But I know a woman who was told to breastfeed her child but the baby was only placed on prophylaxis for six weeks only, you can predict what would happen to her baby.”
This is definitely not what any mother would want to experience after going through PMTCT and the promise of a HIV-negative baby. The cost implication of having your baby through cesarean section and PMTCT services is not one most HIV positive mothers can afford and so for those who are able to pay the price, the joy of having a baby born without HIV is a befitting incentive.
“I did not pay for CS but I spent the total sum of 60,000 for feeding and other things”, says Olotu. Moni’s case was too different. “I chose to have my baby in a general hospital where I had to pay as much as 60,000 naira but the PMTCT service I had to access free of charge.”
With supporting husbands and understanding in-laws motherhood for these working HIV-positive mothers may just be some inspiring success stories. But it has not always been so. “I think the main battle begins with dealing with stigma and having a healthy self esteem the rest things will simply fall in place”, says Moni. And Bose couldn’t agree less. “I have dealt with stigma and discrimination long ago and all I need now is the means to give my children the quality of life they deserve.”
According to the World Health Organisation (WHO), in 2009, about 1,000 babies were infected with HIV every day during pregnancy, birth or breastfeeding. Globally, there are approximately 1.4 million pregnant women living with HIV in low- and middle-income countries. Only 26 per cent of pregnant women living in these countries received HIV tests.
In Eastern and Southern Africa, the region hit hardest by the epidemic, only half of pregnant women were tested for HIV. An estimated 53 per cent of pregnant women living with HIV in the developing world received antiretroviral drugs to prevent them from transmitting the virus to their babies. In Eastern and Southern Africa, 68 per cent of pregnant women living with HIV received antiretroviral treatment.
In a related development, the National Agency for the Control of AIDS (NACA) has revealed that 70,000 infants are infected with HIV/AIDS through mother-to-child transmission in Nigeria annually. Former Director-General of the agency; Professor John Idoko, says that Nigeria bears the largest burden of HIV positive women who transmit to their babies.
He said out of six million pregnancies annually, 230,000 are HIV-positive and mother-to-child transmission results in 70,000 positive infants as the outcome annually, making this group a major source of HIV transmission followed by sex workers. On the prevalence rate of the HIV/AIDS in Nigeria, geographical statistics from NACA, places Benue State as the highest in the country followed closely by Akwa Ibom, Bayelsa, Anambra and the Federal Capital Territory. States like Kebbi, Ekiti, Jigawa and Katsina have very low prevalence rates.
Prof. Idoko called for increased funding to scale up HIV and AIDS response in the country.He made this call at a one-day technical meeting on the President’s Emergency Response Plan for HIV and AIDS (PERP) recently in Abuja. Former President Goodluck Jonathan had unveiled the PERP on May 27, 2012, at a meeting of the AIDSWATCH Africa held on the sideline of the 21st ordinary session of the Assembly of Heads of State and Government of the AU in Addis Ababa.
The PERP is a plan for combating HIV and AIDS scourge. He said that though Nigeria had made some progress, a lot still needed to be done to achieve universal access in 2015. “We need revolution in prevention and treatment to put more people on treatment, all these will not be possible except there is financial revolution,’’ he said.