Important note: Information in this article was accurate in 2001. The state of the art may have changed since the publication date.
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New Vision (Uganda) - September 28, 2001
Joan Mugenzi
As women talked about the drugs for the Prevention of Mother To Child Transmission (PMTCT) of HIV, they were worried about the circumstances under which they are supposed to give birth.The questions then came in.
"We know that if an HIV positive mother got a wound, it would take long to heal. Doesn't the caesarean section (which is recommended for HIV positive mothers) increase the dangers of a mother's wound failing to heal?" asked a participant.
"Given the situation in our hospitals, it is a bit risky. I don not want women who are HIV positive to undergo caesarean section," another participant Agnes chipped in. "It is advisable that an HIV positive woman gives birth by caesarean. But it is difficult to have a mother deliver by caesarean in rural hospitals," said Beatrice Were, the executive co-ordinator of The International Community of Women Living with HIV/AIDS, based in UK.
"An elective caesarean is usually well planned but our facilities are limited, so this puts a woman's life in danger. In the UK, they plan for a woman's caesarean section in the first trimester," she told Women's Vision. A trimester is the first three months of a woman's pregnancy.
Proponents of the caesarean section argue that if an HIV positive woman delivers by caesarean, her baby is most likely to be born free of the virus since a woman does not have to wait in labour for long. Waiting in labour increases the risk of HIV infection to the baby.
"Labour is strenuous. An elective caesarean operation will lessen her strain. If a mother is left to labour, she will use a lot of energy," said Margaret Kidega, a tutor at Mulago School of Nursing and Midwifery. Caesarean section is argued for because once it is elective, the baby does not have to bathe in the vaginal blood secretions that might end up mixing with the baby's blood.
With it (elective caesarean) alone, even without medication, studies that have been carried out in the developed world indicate that the rate of mother to child transmission of HIV to babies reduces by 50%.
Therefore in Uganda, where women are given doses of Zidovudine (AZT) which reduces the rate of transmission by 68% and Nevirapine, which reduces the rate by 50%, caesarean section would further reduce the rate of mother to child transmission of HIV. Dr. Philipa Musoke, a senior lecturer in the department of paediatrics, Makerere Medical School, estimates that if the current antiretrovirals that women are using are coupled with delivery by caesarean section, then, the rate of mother to child transmission of HIV would reduce further.
"We use Nevirapine which is a very simple method because you give one tablet to the mother at the time of labour and one to the child after it has been delivered. If you added caesarean section to that, it would help but it is not a viable alternative, especially in Mulago," Musoke says. The general ward in Mulago Hospital is usually flooded with mothers in labour. Some of them lie in the corridors.
This does not only happens at Mulago. Hospitals in Uganda are stretched in terms of facilities and personnel, for which are much needed for a caesarean section calls for. There are not enough doctors to carry out operations. You may find that there is one doctor on call with many interns to supervise at any given time. The caesarean section thus would not be possible given the fact that it calls for so many resources.
Musoke says she cannot advise women in Uganda to give birth by caesarean save for those who can afford to attend private health units.
In developed countries where HIV positive mothers are treated with triple therapy (which reduces HIV transmission by 75%) and then deliver by caesarean section, the rate of mother to child transmission of HIV is even less than 1%.
"Caesarean section is not the answer to our problem," she says. "We have been using drugs (Nevirapine and AZT) and addressing the issue of infant feeding. We should try and concentrate on where we are. And because of the complications associated with it, I cannot recommend it," Musoke adds.
The complications surrounding a caesarean section are that one can get an infection at the site, especially if not done in a sterile manner. Hence, one may get puss around and inside the abdomen. One may also experience bleeding later.
These two scenarios, Musoke observes, may worsen with a mother living with HIV, whose immunity is low because she may take longer to heal.
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