Salome Maswime, University of the Witwatersrand and Gwinyai Masukume, University of the Witwatersrand

Caesarean sections have been lifesaving procedures for hundreds of thousands of women across the world who experience complications during labour.

Globally, it’s estimated that just under 20% of births take place via caesarean section – a percentage that’s gone up over the last three decades. This has raised concerns, particularly in high-income countries where generally too many caesarean sections are performed.

But in many African countries women who are medically required to have caesarean sections are not able to access them. This is due to several reasons, the most prominent being weak health systems and a lack of resources.

This needs to be fixed as women in sub-Saharan African suffer from the highest maternal mortality ratio in the world. Close to 550 women die for every 100 000 children that are born. This amounts to 200 000 maternal deaths a year – or two thirds of all maternal deaths per year worldwide.

Some of these deaths could be prevented if skilled health personnel were able to perform caesarean sections safely. But this would require proper equipment and supplies including drugs and blood transfusions.

Research shows that low-income countries with the lowest caesarean section rates also have the highest maternal mortality rates.

Improving the access and availability of caesarean sections on the continent is therefore pivotal to reducing the number of maternal deaths and to achieve the sustainable development goal on maternal health of reducing maternal deaths to less than 70 per 100 000 live births by 2030.

Africa’s challenge

Between 1990 and 2015 maternal mortality dropped by about 44% across the world. And several countries in Africa have halved their levels of maternal mortality between 1990 and 2015. In Mali, for example, 1010 women died for every 100 000 children born in 1990. By 2015, this figure dropped to 587.

Despite this massive reduction, more than 800 women continue to die from preventable causes around childbirth every day, most in sub-Saharan Africa and South Asia. And millions more will suffer serious injuries, infections, complications or disabilities due to insufficient treatment.

The World Health Organisation has found that in countries where at least 10% of women have caesarean sections the number of maternal and newborn deaths decrease.

The organisation has not identified an ideal caesarean section rate, however there’s evidence that rates above 20% at country level might be to too high. But it encourages governments to make every effort to provide the procedure to women in need of it.

Africa has the lowest caesarean section rate in the world. In Europe about a quarter of births are conducted via caesarean section while Latin America and the Caribbean have caesarean section rates of about 40.5%.

In Africa only 7.3% of babies are born via this method. But it’s a very mixed picture across the continent. Some countries have very high rates such as Egypt (51.8%) and Mauritius (47%), the highest in Africa. And despite a 2.9% overall increase across the continent from 1990, there’s been a decline in some countries like Nigeria and Guinea which now stands at about 2%. Zimbabwe has maintained its caesarean section rates at 6%.

When caesars matter

Caesarean sections often happen at the end of a series of complex events. There can be both pre-existing and pregnancy related complications. The need for caesarean sections can be aggravated by a range of issues such as delays in accessing the appropriate level of care, transportation delays as well as a shortage of necessary technologies.

Complications require prompt access to quality obstetric services equipped with life-saving drugs, including antibiotics, and the ability to provide blood transfusions or other surgical interventions.

But there are several barriers to improving the caesarean section rates in a country. These include:

• a shortage of midwives, obstetricians, anaesthetists, laboratory and other allied personnel,

• limited access to health care, information and

• a lack of equipment.

Cost is another significant barrier. It was estimated, almost a decade ago, that it would cost US$430 million to perform the almost 3 million additional caesarean sections needed.

Different playing fields

While reducing unnecessary caesarean sections may be a priority in high-income countries, access to it will save more lives, particularly in countries where deliveries in a health care facility are considered a luxury.

Many African countries are trying to increase the number of women delivering in a health care facility by a skilled birth attendant. In Africa, more than 40% of births are not attended by a skilled health provider.

Inequities in access to caesarean sections across different parts of sub-Saharan Africa and other low-income countries need to be addressed. And soon if the continent wants to reduce its unacceptably high maternal mortality rates.

Salome Maswime, Lecturer in Obstetrics and Gynaecology, University of the Witwatersrand and Gwinyai Masukume, Medical Doctor, Epidemiologist and Biostatistician: University College Cork, University of the Witwatersrand

This article was originally published on The Conversation. Read the original article.

I will start by asking two questions: at what age did you know your gender, and do you think someone else had to tell you what it was? I’m director of mental health at a leading gender clinic in the US. Our clinic is a half-decade old – and in that short period the number of families coming to us with questions about their child’s gender has grown astronomically every month.

We’re not alone. The BBC recently reported that the number of children aged ten and under who were referred to the NHS in the UK to help deal with transgender feelings had more than quadrupled in six years.

The main issue that brings children to our clinic is a child in the family who says: “Hey, you’ve got it wrong, I’m not the gender you think I am” or “I do not want to conform to the rules I see around me about how boys are supposed to be boys and girls are supposed to be girls.”

Some of these children are very upset about their gender conundrums; others skip happily outside the gender boxes that were outlined and filled in for them by the culture around them. Yet they all share something in common – feelings about their gender – and depending on how these feelings are negotiated by the adults who care for them, they will either rejoice is their “gender creativity” or suffer from the ill-fit between the gender everyone expects them to be and the gender they know themselves to be.

These feelings can surface as early as the second year of life, when a girl toddler frantically pulls the fancy barrettes out of her hair or a boy toddler wraps his blanket around his head to create long, flowing hair. Or, they can show up much later. Children, like any human, are all different.

All of these children will have had a sex assigned to them at birth. Most children feel quite in sync with that assignment, but a very small number do not. They are the children who often say, in both word and actions: “I’m a boy, not a girl” or: “I’m a girl, not a boy” or come up with some gender category that is neither boy nor girl but something quite in-between.

Other children, fine with the sex assigned to them on their birth certificate but not with the expectations about how they are supposed to perform that gender, might happily engage in the activities that feel best to them, wear the clothes that look nicest to them and play with the children who feel most compatible to them – until they are limited or policed by the socialisation agents in their environment, for example, when a father tells his son that he can’t wear his nail polish in public or a therapist advises parents to take away all their little girl’s “boy” toys. From this point, their feelings may change from jouissance (a sense of unbridled joy or pleasure) to stress or distress if the message mirrored back from the people around them, with strong feeling, is that the way they are “doing” their gender is inappropriate and unacceptable.

An obvious contradiction

In the field of mental health today, and in the general public, a debate is running as to whether young children could possibly know their gender at a young age and whether they might change their mind over time, just as they do about so many other aspects of life. Ironically, if one delves into the Western literature on gender development in young children, such as the work of Robert Stoller or Eleanor Maccoby, or Sigmund Freud before them, we uncover a contradiction.

In traditional theories, it is assumed that children clearly know their own gender by the age of six, based on the sex assigned to them at birth, the early knowledge of that assignment, the gender socialisation that helps a child know how their gender should be performed and the evolving cognitive understanding of the stability of their gender identity. Yet if a child deviates from the sex assigned to them at birth or rejects the rules of gender embedded in the socialisation process, they are assumed to be too young to know their gender, suffering from either gender confusion or a gender disorder.

Following this logic, if you are “cisgender” (your sense of your gender matches the sex assigned on your birth certificate), you can know your gender, but if you are transgender or gender-nonconforming, you cannot possibly know.

Yet a macro survey of transgender adults conducted in the US indicated that a large proportion of respondents knew at an early age what their true gender was – they just kept it under wraps because of social stigma in their childhood years. So we could say that gender-creative children can possibly know their gender – and do, at a very young age.

Messages from brains and minds

Recent clinical observations and research studies, such as a 2013 report from the VU University in Amsterdam, reveal a certain group of young children who are what we refer to in the vernacular as insistent, persistent and consistent in their affirmation of their cross-gender identities. This is not based on the genitalia they perceive between their legs or the gender label given to them by others, but by messages from their own brains and minds.

Research is underway to discover the biopsychosocial pathways to such identities, but it is becoming increasingly clear that chromosomes and external genitalia are not the driving forces for this subgroup of children – our youngest cohort of transgender people.

Those of us who operate within the gender-affirmative model – abiding by the definition of gender health as the child’s opportunity to live in the gender that feels most authentic to them – have developed assessment processes based on the dictum that: “if you listen to the children, you will discover their gender. It is not for us to tell, but for them to say.”

This makes adults nervous, as we were always taught that gender was a bedrock, determined not by the child but by the assessment of the medical professionals delivering the baby: penis for a boy, vagina for a girl. It’s both earthshaking and extremely anxiety provoking to have that trope challenged by young voices who might say to us that we got it wrong. And if the child is wrong and we go along with them, we could make a mess of things by having them bounce back and forth between genders or take the wrong path.

Over the course of time, if we do not impose our own reactions and feelings on the children, like the ones above, and allow a space for their gender narrative to unfold, the gender they know themselves to be will come into clearer focus. From there we can give them the opportunity to transition to the gender that feels most authentic, followed later by the choice to use puberty blockers to put natal puberty on hold and later cross-sex hormones to bring their bodies into better sync with their psyche.

If we do not give them this opportunity, they may feel thwarted, frustrated, despondent, angry, deflated – feelings reflected in the symptoms correlated with being a gender-nonconforming or gender-dysphoric child. The root of these symptoms is not the child’s gender, but rather the environment’s negative reactions to the child’s gender.

When acceptance and allowance of the child to live in their authentic gender replace negation or suppression of a child’s nonconforming gender, the symptoms have been known to subside or disappear completely, much to the surprise of those caring for the child. We might even consider gender as the cure, rather than the problem, privileging the child’s ability to not only feel, but know their gender.

Diane Ehrensaft is Director of Mental Health at the Child and Adolescent Gender Center at University of California, San Francisco.

This article was originally published on The Conversation.
Read the original article.