Delays in the awareness campaign and roll-out of the federal government?s free Caesarean Section (CS) initiative have further raised doubts about the laudable initiative.

The programme, aimed at reducing the high maternal mortality in the country, was disclosed in November last year but is yet to come upstream about three months later.

While practitioners are optimistic about its impacts in the delivery wards and indigent homes, pregnant women in need said it may go the way of the government?s N40,000 per bag of rice.

The Guardian learnt that the initiative, tagged: ?Supporting Financial Access to Comprehensive Emergency Obstetric and Neonatal Care (CEmONC)? in the incubation stage, though hobbled by the search for accurate data on beneficiaries and designated facilities, coupled with its budget.

The CEmONC Initiative, under the care of the National Health Insurance Authority (NHIA), has good intentions amid Nigeria?s high maternal mortality rate.

In 2023, the World Health Organisation (WHO) estimated Nigeria?s maternal mortality ratio to be 1,047 deaths per 100,000 live births, the world?s second-highest. These indices reflect a concerning situation, especially given the potential attainment of the Sustainable Development Goals (SDGs) target of less than 70 deaths per 100,000.

Amid the recent spike in the cost of living, the attendant rise in the price of care and child delivery, especially caesarean section, has been an albatross in many poor yet expectant families.

Random estimates showed that the prevalence of CS in every labour ward in Nigeria ranges between two and 2.7 per cent.

CS delivery costs vary from one facility to another and are considered cheaper in government-owned health facilities. CS is relatively more affordable if the expectant mother has antenatal care in the same hospital, regarded as booked CS, while the unbooked CS is often on the high side.

For instance, while a Cesarean section may cost between N40,000 and N300,000 in government-owned medical facilities, depending on the location and prior record (booked or unbooked), the exact procedure costs about N500,000 and above in private hospitals.

A breakdown of the CS tariff plan obtained from the Federal Medical Centre (FMC) Jabi, Abuja, which comprises ANC details for General and VIP, showed that booked CS for general costs N250,000, while unbooked CS is N300,000.

In the same facility, ANC and CS for VIPs cost N747,000, while ANC and delivery (vaginal delivery) costs N447,000.

At the Wuse General Hospital, the total cost for booked CS, including costs of antenatal care, delivery package, laboratory tests, drugs and other miscellaneous costs, is about N250,000.

Pregnant women who spoke with The Guardian described the move as a welcome development, though they were sceptical of its effective implementation.

At a Primary Healthcare Centre in Kuchingworo, a rural settlement near the Abuja City Gate, an expectant mother, Aisha, said she heard about the free Cesarean section about five weeks ago but was unsure if the implementation had started.

She said: ?The plan is excellent, but you know that in this country, the government always makes promises, but at the end of the day, you will not hear about it again. That was how they promised to sell 50kg of rice to us at N40,000. Up till now, we have not seen the rice. The government should keep to its promise because CS is expensive, and many women cannot afford it, especially in the villages.?

A civil servant, Mrs Anaesthesia, who is pregnant with her first child, told The Guardian that the initiative is good, but she didn?t pray to deliver through the Cesarean section.

One of the nurses in the facility said she was happy when she heard the news about the free CS on the radio because of the challenges some women go through in general hospitals.

?We usually refer pregnant women to the General Hospitals when we find out that they cannot deliver by themselves due to one health issue or another, but most of them encounter severe delays because they don?t even have money to pay for the procedure.

?Our prayers are that the government starts the programme because it will have a lot of benefits for our women. It will reduce maternal mortality and morbidity, as well as reduce their financial burden.?

Sources at the Federal Ministry of Health and Social Welfare told The Guardian that the government is tidying up the process to ensure a hitch-free take-off of the initiative, after which it would announce the commencement date for the programme.

The Director-General of the National Health Insurance Authority (NHIA), Dr Kelechi Ohiri, said the programme would be implemented through accredited healthcare facilities that meet the required standards to ensure women access timely, high-quality care.

Ohiri noted that the NHIA Financing Access to the CEmONC initiative stems from the critical need to address the alarming maternal mortality rate in the country.

He observed that poor and vulnerable women often face financial barriers to accessing life-saving interventions, which include emergency caesarean sections.

Ohiri stated that the programme was designed to address the five leading causes of maternal mortality, which include haemorrhage, sepsis, hypertensive disorders, unsafe abortions, and obstructed labour, by providing a comprehensive package of interventions expected within the CEmONC framework, including emergency obstetric surgeries and blood transfusion services.

On measures being put in place to ensure that the initiative is not exploited or abused, Ohiri said: ?The NHIA initiative is built on a framework of accountability and transparency to ensure that resources are directed to the poor and vulnerable women in need of it the most. Measures are in place, leveraging systems and data-driven mechanisms to identify eligible beneficiaries and track service delivery.

?We ensure accurate identification and targeting through facility, state, and national registers, coupled with using the National Identification Number (NIN). Additionally, third-party administrators (TPAs) are engaged to verify claims, providing an added layer of oversight and ensuring that all processes are fair, efficient, and effective.

?Routine monitoring and oversight are integral to the programme, safeguarding its integrity and delivering its intended impact for the poor and vulnerable women who need it most.?

On pregnant women already covered by health insurance, Ohiri said, ?The NHIA financing access to the CEmONC programme is specifically designed for poor and vulnerable women. It addresses their index case?in this instance, an obstetric emergency?and ensures they receive the necessary life-saving care.

?Beyond that, the programme provides a sustainable pathway for continued access to essential health services by enrolling beneficiaries into health insurance. This is achieved by leveraging the Basic Health Care Provision Fund (BHCPF) or equivalent platforms. We focus on eliminating financial barriers and fostering a system where every woman can access quality maternal healthcare regardless of her insurance status.?

MEANWHILE, the Nigeria Medical Association (NMA) and the National Association of Resident Doctors (NARDs) have applauded the initiati?e, saying that it will go a long way in reducing the country?s high incidence of maternal mortality.

NMA President, Prof. Bala Audu, who commended the Federal Government?s initiative, called for effective implementation.

Audu, an Obstetric-Gynaecologist at the Federal University of Health Sciences Teaching Hospital, Azare, told The Guardian that the hospital handles about 300 CS deliveries every month, representing about eight CS deliveries daily.

Audu said: ?The pronouncement by the Federal Government is highly commendable as the key indications for caesarean sections are often life-saving indications for the mother and life-saving indications for the unborn baby.

?So, by offering free caesarean section, particularly to women who may not be able to afford it at the point of need, will drastically reduce the delay in doing caesarean section and reduce the maternal mortality and perinatal mortality.?

He noted that by ensuring that women with indications of caesarean section have it as and when due, the country would significantly save the lives of these mothers and their babies.

The NMA President, who stressed the need to ensure that this initiative is well-funded, considering that the programme will be done through the NHIA, called for appropriate documentation and proof of service that the caesarean section was done.

?So, there should be proof of delivery of the service in the caesarean section before any claims are made for payment, and this payment should also be done immediately, preferably, but maybe on a monthly or fortnightly basis so that health facilities are encouraged to offer this service without delay.

?And, like you rightly pointed out, there is a risk of abusing such, but the important thing is that we know that medical practices are well regulated by the Medical and Dental Council of Nigeria, and therefore, we believe that physicians on their own will not do a caesarean section for an individual for whom there is no indication.?

Audu, however, argued that pregnant women who can deliver by themselves but out of choice prefer to have an elective caesarean section should be made to bear the cost of their caesarean section.

?Those who want to do what is referred to as a caesarean section by choice, which means these are women who, out of informed choice, decide that they don?t want to have a vaginal delivery but would prefer to have an elective caesarean section, even though they can deliver by themselves.?

The NMA president appealed to members to embrace the initiative with a high sense of patriotism and not to delay cesarean section where there is an indication and offer prenatal advice that is highly responsible and ethical, and not do anything that will harm the patient.

He equally urged pregnant women to be aware of their rights and not to allow them to be coerced into having a Cesarean section that they do not want.

President of the National Association of Resident Doctors (NARDs), Dr Tope Osundara, while applauding the initiative, reckoned that maternal mortality remains an issue affecting women of reproductive age in Nigeria

He said: ?We have records of death from pregnancy-related causes. Some of these deaths are preventable if the right care and treatment are made available.?

He called on the Federal Government to work with NMA, NARDs or the Association of Nigerian Private Medical Practitioners, which are bodies familiar with the government and involved in outreaches that have far-reaching effects on the populace.

The NARD president observed that every process and intervention from the government comes with some challenges and advised that to ensure transparency and accountability, registered women who have been regular with their antenatal clinic visits should benefit from this intervention.

?If the government can ensure the proper selection of women and offer intervention to those who need it, especially the poor, I think it is a step in the right direction. All that is required is to get the data from local health facilities in different communities, especially the Primary health centres or community clinics. This will also encourage antenatal visits, especially in some rural communities.

?The PHC, for example, will have the details of women attending antenatal. When the biodata and other medical records are collected, the government can work with established tertiary or secondary health centres to carry out the C-section,? Osundara added. (The Guardian)

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