**3.1 Background**

There are many risk factors that can compromise childbirth and motherhood as far as emergency caesarean section is concerned in limited resources settings. Among these is parity, namely nulliparity and multiparity [33, 34]. Concerning nulliparity in general, it is worldwide known that nulliparous women are at higher risk of pregnancy, delivery and neonatal complications. They are prone to anaemia, pre-eclampsia, anal sphincter injury, operative vaginal delivery, postcaeserean surgical site infection, dystocia, caesarean delivery, inadequate uterine contractions, foetal malposition, cephalopelvic disproportion, premature labour, low birth weight, funisitis, neonatal morbidity, perinatal mortality, induction of labour, routine episiotomy, hypertensive complications, and postpartum haemorrhage [33–42]. The situation is similar for teenagers who are pregnant [43]. All these cases become very worrying when it comes to pregnant women living in remote areas of conflict or postconflict regions, and even in urban areas in absence of qualified health professionals, suitable motivation and appropriate equipment. Rwanda is a postconflict region while DRC is still a conflict region, especially the eastern part of the country. The situation is most crucial in DRC when Rwanda is doing well as far as Universal Health Coverage and MDG achievement are concerned [44, 45].

### **3.2 Findings in Rwanda and DRC**

A recent health facility-based cross-sectional study has been carried out in Rwanda (Kigali and Northern Province) from 2014 to 2015 through structured interviews and medical records (*n* = 817). This study has shown a higher rate of nulliparity (41.1%) as assessed through self-reported data from postpartum women [46]. This should not be shocking, as there are many young marriages in Rwanda after the 1994 genocide for reasons that are understandable. However, this high rate of nulliparity is also accompanied by high levels of risk associated with first pregnancy and childbirth. A previous cross-sectional case–control study (n = 600) at Muhima District Hospital in Kigali has shown in 2009 that nulliparous women were at higher risk than multiparae with regard to many obstetrical and neonatal outcomes. Nulliparous women were significantly prone to: lower weight (*p* = 0.016); malaria crisis (*p* = 0.031); induction of labour (*p* = 0.008); caesarean delivery (*p* < 0.001); episiotomy (*p* < 0.001); failure of descent (*p* = 0.037); transfer to neonatal care (0.025), and lower average birth weight (*p* < 0.001) [41].

In DRC, a recent cross-sectional and analytical study of singleton births in postpartum women (*n* = 4197) reported, from December 2013 to May 2014, a nulliparity rate of 19.9% in 10 referral maternity hospitals in Lubumbashi, Upper Katanga Province. Primiparous women (i.e. nulliparous before delivery) as compared with multiparae were during pregnancy at higher risk for: high blood pressure (OR = 1.91 [1.32–2.74]); malpresentation (OR = 1.95 [1.16–3.17]); oxytocin use (OR = 2.03 [1.64–2.52]); caesarean section (OR = 2.04 [1.47–2.83]); episiotomy (OR = 11.89 [8.61–16.43]); eclampsia (OR = 4.21 [1.55–11.44]); lower rate of 5th minute APGAR score (OR = 1.55 [1.03–2.32]); and higher rate of early neonatal mortality (OR = 1.80 [1.08–2.98]) [47].

## **4. Caesarean section delivery**

#### **4.1 Background**

It has been suggested by the World Health Organisation (WHO) that caesarean section rate should range between 5 and 15% in order to benefit to mother, foetus and newborn [48, 49]. Therefore, a rate above 15% is assimilated to unjustified use of surgical delivery, while a rate below 5% reveals a population's lack of access to medical technology [31]; besides, evidence based results show that there is no correlation, at population level, between caesarean rates higher than 10% and reduction of maternal and newborn mortality [50]. Nowadays, more and more claims around the world stigmatise the shocking rising trends of caesarean section, especially in private sectors as 'on demand caesarean section' or 'caesarean section on maternal request' has become a routine indication in medical practice [51, 52]. Given maternal and perinatal complications associated with caesarean section, efforts are recommended to provide surgical delivery to only women in real need, assuming that the medical environment is appropriate [50]. Thus, there is a need to be more cautious as regards caesarean section indications and quantity regulation in order to reduce health costs as well as maternal and foetal risks [50, 51]. In this regard, the prevailing situation in the countries of African Great Lakes region is generally frightening, particularly in DRC given the conflict or postconflict environment.

**77**

**5.1 Background**

*Safe Childbirth and Motherhood in African Great Lakes Region: External Pelvimetry…*

For more than a decade, different scientific reports in Rwanda have revealed higher rates of caesarean compared to the upper limit (15%) for caesarean section set by WHO. In 2006 and 2007, two descriptive cross-sectional studies found caesarean section rates of 41% and 33.7% in a urban national reference hospital (Kigali city) and a rural district hospital (Northern Province), respectively [53, 54]. Two other crosssectional studies (descriptive and case-control) conducted in 2008 and 2009 have also shown higher rates of caesarean, i.e. 21.05% and 28% (versus 10.7% in multiparae), in nulliparous women from a rural area (Huye/Southern Province; n = 152) and Kigali city (n = 600), respectively [41, 55]. In DRC, a retrospective study was carried out in Lubumbashi on 34,199 deliveries from five referral hospitals for a period of five years (2009 to 2013). This study noticed an overall caesarean section rate of 10.65% with a slight increase from 2009 (10.24%) to 2013 (11.38%). Almost one caesarean section out of two (48.6%) occurred in an emergency context and the majority (51.4%) of caesareans after unsuccessful attempt to give birth naturally. Unfortunately, the 11% increase in caesareans did not bring any benefit in terms of foeto-maternal prognosis as there was no significant change in perinatal mortality rate whereas overall maternal mortality rate jumped from 2.3‰ in 2009 to 6.4‰ in 2013, which was a highly significant 317.5% increase (p = 0.005) [56]. Five months later (December 2013–May 2014), an abovementioned analytical cross-sectional study on primiparae (nulliparae before delivery) reported in the same environment a caesarean rate of 13.03% (versus 6.84% in multiparae) in postpartum primiparous women with a poor neonatal outcome [47].

**5. External pelvimetry and ways of delivery in nulliparae and multiparae**

Since more than two centuries, women pelvic architecture and pelvic girdle measurements have been a matter of scientific concern for obstetricians. Women pelvis and pelvimetry have been deeply studied in the eighteenth and the nineteenth century by a number of eminent scientists among whom Hendrik Van Deventer, Jean Louis Baudelocque, Gustav Adolf Michaelis, Franz Karl Joseph Naegele, Stein Jr., and Carl Conrad Theodor Litzman [57]. Different types of pelvimeters became common tools in maternity wards and delivery rooms. In the past, young trainees in medicine, assistants in obstetrics and midwives constantly and regularly used these pelvimeters, which were familiar to them. Gradually, this instrument disappeared from hospital maternities to end up only in a few health centres held by old nuns. This was the case in Rwanda and DRC. Moreover, the effectiveness of pelvimeter has for some time become questionable for most obstetricians under the pressure of advances in technology during the ending twentieth century and given the alleged lack of satisfactory scientific evidence [21, 22]. However, we are still living in a world where health care equity and access to quality health care remain to date an unattainable dream worldwide and even when it comes to different social classes within some industrialised countries. Therefore, it is the duty of scientists and men in the field to look for simple ways and inexpensive tools to help the many left behind, especially young pregnant women in resource-constrained countries in an environment dominated by all kinds of barriers. It is in this context that a number of studies have been conducted on the relationship between anthropometric parameters including height, weight as well as external pelvic diameters and ways of delivery in some parts of the world, and more particularly in Sub-Saharan Africa, Central Africa and African Great Lakes region [25–28]. Reported findings below are

*DOI: http://dx.doi.org/10.5772/intechopen.89638*

**4.2 Findings in Rwanda and DRC**

*Safe Childbirth and Motherhood in African Great Lakes Region: External Pelvimetry… DOI: http://dx.doi.org/10.5772/intechopen.89638*

## **4.2 Findings in Rwanda and DRC**

*Maternal and Child Health Matters Around the World*

**3.2 Findings in Rwanda and DRC**

mortality (OR = 1.80 [1.08–2.98]) [47].

**4. Caesarean section delivery**

**4.1 Background**

the country. The situation is most crucial in DRC when Rwanda is doing well as far as Universal Health Coverage and MDG achievement are concerned [44, 45].

A recent health facility-based cross-sectional study has been carried out in Rwanda (Kigali and Northern Province) from 2014 to 2015 through structured interviews and medical records (*n* = 817). This study has shown a higher rate of nulliparity (41.1%) as assessed through self-reported data from postpartum women [46]. This should not be shocking, as there are many young marriages in Rwanda after the 1994 genocide for reasons that are understandable. However, this high rate of nulliparity is also accompanied by high levels of risk associated with first pregnancy and childbirth. A previous cross-sectional case–control study (n = 600) at Muhima District Hospital in Kigali has shown in 2009 that nulliparous women were at higher risk than multiparae with regard to many obstetrical and neonatal outcomes. Nulliparous women were significantly prone to: lower weight (*p* = 0.016); malaria crisis (*p* = 0.031); induction of labour (*p* = 0.008); caesarean delivery (*p* < 0.001); episiotomy (*p* < 0.001); failure of descent (*p* = 0.037); transfer to

neonatal care (0.025), and lower average birth weight (*p* < 0.001) [41].

In DRC, a recent cross-sectional and analytical study of singleton births in postpartum women (*n* = 4197) reported, from December 2013 to May 2014, a nulliparity rate of 19.9% in 10 referral maternity hospitals in Lubumbashi, Upper Katanga Province. Primiparous women (i.e. nulliparous before delivery) as compared with multiparae were during pregnancy at higher risk for: high blood pressure (OR = 1.91 [1.32–2.74]); malpresentation (OR = 1.95 [1.16–3.17]); oxytocin use (OR = 2.03 [1.64–2.52]); caesarean section (OR = 2.04 [1.47–2.83]); episiotomy (OR = 11.89 [8.61–16.43]); eclampsia (OR = 4.21 [1.55–11.44]); lower rate of 5th minute APGAR score (OR = 1.55 [1.03–2.32]); and higher rate of early neonatal

It has been suggested by the World Health Organisation (WHO) that caesarean section rate should range between 5 and 15% in order to benefit to mother, foetus and newborn [48, 49]. Therefore, a rate above 15% is assimilated to unjustified use of surgical delivery, while a rate below 5% reveals a population's lack of access to medical technology [31]; besides, evidence based results show that there is no correlation, at population level, between caesarean rates higher than 10% and reduction of maternal and newborn mortality [50]. Nowadays, more and more claims around the world stigmatise the shocking rising trends of caesarean section, especially in private sectors as 'on demand caesarean section' or 'caesarean section on maternal request' has become a routine indication in medical practice [51, 52]. Given maternal and perinatal complications associated with caesarean section, efforts are recommended to provide surgical delivery to only women in real need, assuming that the medical environment is appropriate [50]. Thus, there is a need to be more cautious as regards caesarean section indications and quantity regulation in order to reduce health costs as well as maternal and foetal risks [50, 51]. In this regard, the prevailing situation in the countries of African Great Lakes region is generally frightening, particularly in DRC given the conflict or postcon-

**76**

flict environment.

For more than a decade, different scientific reports in Rwanda have revealed higher rates of caesarean compared to the upper limit (15%) for caesarean section set by WHO. In 2006 and 2007, two descriptive cross-sectional studies found caesarean section rates of 41% and 33.7% in a urban national reference hospital (Kigali city) and a rural district hospital (Northern Province), respectively [53, 54]. Two other crosssectional studies (descriptive and case-control) conducted in 2008 and 2009 have also shown higher rates of caesarean, i.e. 21.05% and 28% (versus 10.7% in multiparae), in nulliparous women from a rural area (Huye/Southern Province; n = 152) and Kigali city (n = 600), respectively [41, 55]. In DRC, a retrospective study was carried out in Lubumbashi on 34,199 deliveries from five referral hospitals for a period of five years (2009 to 2013). This study noticed an overall caesarean section rate of 10.65% with a slight increase from 2009 (10.24%) to 2013 (11.38%). Almost one caesarean section out of two (48.6%) occurred in an emergency context and the majority (51.4%) of caesareans after unsuccessful attempt to give birth naturally. Unfortunately, the 11% increase in caesareans did not bring any benefit in terms of foeto-maternal prognosis as there was no significant change in perinatal mortality rate whereas overall maternal mortality rate jumped from 2.3‰ in 2009 to 6.4‰ in 2013, which was a highly significant 317.5% increase (p = 0.005) [56]. Five months later (December 2013–May 2014), an abovementioned analytical cross-sectional study on primiparae (nulliparae before delivery) reported in the same environment a caesarean rate of 13.03% (versus 6.84% in multiparae) in postpartum primiparous women with a poor neonatal outcome [47].
