**6. Home-birth practice and vaginal childbirth at all costs**

### **6.1 Background**

*Maternal and Child Health Matters Around the World*

**Diameters (cm) Contracted pelvis** 

Antero-superior Iliac interspinous

**(***N* **= 9)**

*5.2.7 Pelvic dystocia and external pelvic diameters in DRC*

*External pelvimetry and caesarean section indication in Rwandan nulliparae.*

A cross-sectional descriptive study with an analytical component in nulliparae (*n* = 535) was conducted in seven referral hospitals in the city of Lubumbashi from February 2016 to August 2017 in order to describe the morphological characteristics (anthropometric and pelvimetric externally) and to identify their thresholds for the specification of appropriate determinants and the development of a predictive score for the type of delivery (vaginal versus caesarean) in pregnant women. Only 535 nulliparae who gave birth with singleton pregnancy at term and vertex presentation were involved in this study; and only caesarean sections indicated for mechanical dystocia were considered. A predictive score (TABIT score: TA for "taille", i.e. height; BI for "bi-ischiatique", i.e. intertuberous; and T for "Trillat", i.e. prepubic diameter) was defined after logistic modelling to predict the occurrence of mechanical dystocia. Three criteria emerged as predictors (determinants) of mechanical dystocia: maternal height < 150 cm (OR adjusted = 2.96 [1.49–5.87]), bi-ischiatic or intertuberous diameter < 8 cm (OR adjusted = 15.96 [3.46–73.56]) and Trillat's triangle base or prepubic diameter < 11 cm (OR adjusted = 2.34 [1.36–4.01]). The total number of points attributed to the three determinants was 5 (<2 = low risk,

Biiliac 22.83 ± 2.59 23.45 ± 1.34 0.62 0.375

Intertrochanter 25.70 ± 2.56 27.72 ± 2.26 2.02 0.036 Baudelocque 16.20 ± 1.17 18.50 ± 1.31 2.30 0.001 Intertuberous 7.76 ± 0.43 9.26 ± 0.68 1.50 0.001 Trillat's base 12.17 ± 2.26 13.98 ± 0.93 1.81 0.003

**Other indications (***N* **= 23)**

20.87 ± 1.59 21.94 ± 1.15 1.07 0.043

**Mean difference** *p***\***

*5.2.6 Caesarean section indications and external pelvic diameters in Rwanda*

A cross-sectional and analytical study was made on data collected from 32 operated parturients among 152 nulliparae who gave birth with singleton pregnancy at term and vertex presentation within the three first months of the abovementioned prospective longitudinal survey in the Southern Province of Rwanda [61]. Anthropometric measurements (external pelvic diameters in cm) were collected at first antenatal care consultation. At childbirth, midwives and physicians monitored labour in a blind way and the following data were collected after delivery by the investigators: way of delivery (per vaginam or caesarean section), and caesarean section indication. Student's *t* test was used to compare mean values from a normally distributed population (Kolmogorov-Smirnov test). This study showed a relationship between external pelvic sizes and caesarean section indications related to obstructed labour due to pelvic dystocia. Clinically diagnosed pelvis contraction was characterised by smaller average measurements in comparison with other caesarean section indications. Apart from biiliac (intercrestal) diameter, observed differences were statistically significant for all other external pelvic diameters, i.e. antero-superior iliac interspinous, intertrochanter, Baudelocque's, and intertuberous (**Table 8**) [55].

**82**

*\**

**Table 8.**

*Student's t test.*

Home-birth practice usually happens in remote rural areas where qualified health professionals are rare, even absent or unknown; this is the case in most conflict areas of DRC and particularly in Upper Katanga province for several years past. In these conditions, the matrons are at work without any restraint. The tacit rule is to give birth whatever the cost by natural way. In a context of financial and geographical barriers, and facing the lack of qualified health staff coupled with the lack of adequate infrastructure and equipment, one has no choice but to wait for a possible favourable evolution of childbirth under the supervision of the matrons or any other person in charge of the parturients in the community who often do not hesitate to resort to the traditional medication. All this may result in obstructed labour or dystocia, which often occurs when the foetal head is stuck in the mother's pelvis, interrupting blood flow to the surrounding tissues. This results afterwards in prolonged ischemia which may progress to tissue necrosis, the fall of which leads to fistulas formation. Most of the time, cephalopelvic disproportion, which is one of the most frequent indications of caesarean section in nulliparae in our environment [41, 55, 56], is the primum movens of this process. Obstetric fistulas (urogenital) have debilitating consequences such as urinary incontinence, faecal incontinence or both, and damage to the vulva and thighs. They bring about well-known social ostracism and dehumanising stigmatisation with a urge impact on social, psychological, and sexual life of patients, more particularly in a context of extreme socioeconomic precariousness. In developed countries the incidence of vesicovaginal fistula is 0.3–2%, while it is not known in developing countries because of the underreporting of cases; and if it can be annually estimated, only a certain portion can benefit from treatment [65–67].

#### **6.2 Findings in DRC**

A descriptive cross-sectional study was carried out from September 2009 to December 2013 in Upper Katanga Province (DRC) after five mass treatment campaigns in six health districts (Pweto, Kilwa, Mitwaba, Kasenga, Kashobwe and Lubumbashi). This study that involved 242 patients depicted a gloomy situation about sociodemographic and obstetrical characteristics of these patients at the time of fistula: 40.1% aged <20, 90.6% of nulliparae, 94.6% of vaginal delivery; 85.9% of ≥48 hours labour duration, 70.7% of home-birth practice, 93.4% of neonatal mortality, and 71.5% of patients living alone. Clinical parameters related to fistula were as follows: a history of fistula of 5 years and more (33.5%), vesico-vaginal fistula (96%) and failure of fistula repair (14%) [68]. This situation is only the tip of an iceberg as not all women concerned could be reached by the awareness campaigns.

Therefore, it is obvious that obstetric fistula is a real public health problem in the DRC, and particularly in nulliparae. Concerning prolonged labour and caesarean section performed under inappropriate conditions, other equally serious complications are uterine rupture, which compromises the reproductive capacity, as well as the high maternal and perinatal morbidity and mortality. And yet all this would be avoidable if we could act upstream by predicting the outcome of the pregnancy (i.e. the way of delivery) with a high probability so that the maternal and perinatal prognosis could be considerably improved.
