C-section vs natural birth: Why are expectant moms increasingly coming under the scalpel?
To introduce transparency, the Central Government Health Scheme plans to ask all empanelled hospitals and clinics to display their c-section rates prominently at reception counters.
Every year, as many as 6.6 million babies – a figure equivalent to Ireland’s population – are born in India through caesarean-section (c-section) surgery.
The number has more than doubled in the past decade, going up from 8.5% of the total births in 2005-06 to 17.2% in 2015-16. During the same period, institutional deliveries – births at hospitals, health centres and clinics – also doubled from 38.7% to 78.9%, data released by the National Family Health Survey-4 in 2017 shows.
“C-sections are effective in saving maternal and infant lives, but only when required for medical reasons. At the population level, c-section rates higher than 10% do not lower mother and newborn deaths,” said the World Health Organisation (WHO) on c-section in 2015, after a systematic review of scientific literature.
Globally, 18.6% of all births occur through c-section surgery, ranging from 6% in less-developed to 27.2% in more-developed regions, data from 150 countries till 2014 shows. The c-section rate worldwide increased by 12.4% (from 6.7% to 19.1%) between 1990 and 2014.
So, are instances of c-section surgery rising because it minimises chances of birth complications (such as preterm births and cephalic, breech or transverse foetal presentations) or does it simply feed commercial and non-medical interests?
To introduce transparency, the Central Government Health Scheme (CGHS) plans to ask all empanelled hospitals and clinics to display their c-section rates prominently at reception counters. If hospitals don’t comply, they will risk losing CGHS empanelment and, with it, several thousands of CHGS beneficiaries whose treatment is paid for by the government.
Is less better?
C-section rates in rural India (12.9%) are closer to WHO recommendations, but its urban count – 28.3% – is nearly three times that. The rates hover around 50% at many private tertiary-care hospitals in Indian cities.
Tertiary medical institutions such as the All India Institute of Medical Sciences and district hospitals across the country show higher c-section rates than the population average because complicated pregnancies are often referred there. “At the institution level, low c-section rates are often not the best indicator of quality and ethical healthcare because states with the worst public health infrastructure often have the lowest rates. They simply don’t have the infrastructure or human resources to conduct c-section deliveries,” says Dr Neerja Batla, professor of gynaecology and obstetrics, All India Institute of Medical Sciences (AIIMS).
A substantial number of emergency c-section cases are referred to other medication institutions even from the AIIMS-run government hospital (Comprehensive Rural Health Services Project) at Ballabhgarh in Faridabad because it has no anaesthetist on weekends.
The most common medical causes for c-section are large or premature babies, routine repeat caesareans, non-progressive labour, breech presentation, foetal distress, prematurity, in-vitro fertilisation, and late age of conception.
“Technology capable of monitoring foetal distress has made it possible to save babies as young as 25 weeks. The priority of doctors is to safeguard the mother and child in the safest way possible,” says Dr Rishma Pai, president, Federation of Obstetricians and Gynaecologists of India.
A convenient truth
In 2015, WHO recommended the Robson classification system as the global standard for assessing, monitoring and comparing c-section rates at healthcare facilities to ensure that it is performed only for medical reasons.
“C-section rates at private hospitals and clinics are often higher than government medical colleges and district hospitals, where junior doctors and post-graduate students are available on a 24x7 basis. Doctors at private centres don’t want to wait around for a natural delivery, which can occur at a time inconvenient to them,” says a health ministry official.
Moreover, a large number of private sector doctors visit more than one hospital or clinic – making unplanned deliveries inconvenient. “Opting for a c-section helps them plan their day and also make more money for the hospital,” claims 34-year-old Sailesh Manchanda, who believes his wife’s obstetrician opted for the scalpel even when all her health parameters were normal.
“I got a second opinion after my daughter was born, and was told there was no need for a c-section,” says Mandhanda, whose daughter – Siya – is now five. His second child, Nimish, had a natural birth at a different hospital earlier this month.
Is it a choice?
Doctors at private hospital also tend to practise “defensive obstetrics”, where litigation fears make them choose to deliver the baby through surgery at the first sign of trouble. “If the baby is born with a birth-related defect, who will be held responsible? This is about human life, and the quality of life cannot be compromised,” says Dr Pai, who differs with the government on forcing hospitals to display c-section rates. “Such a step may pressurise some hospitals to reject complicated pregnancies.”
The ministry official shrugs off her objection. “We just want transparency, and what’s best for the mother and child,” he says.
Following a UK Supreme Court judgment in 2015 that compensated a baby who suffered brain damage during a vaginal birth inadvisably conducted on a woman with diabetes and a small pelvis, all doctors are officially required to warn expectant mothers on the risks posed by both c-section and natural births. Some of them pick c-section in the hope of avoiding labour pain. “Conducting c-section by saying that the mother wanted one is no excuse. Doctors have to inform her that epidural anaesthesia makes delivery painless,” says Dr Batla.
Incidentally, surgery comes with its own risks – anaesthesia complications, infections, haemorrhage, scarring, injury to other organs, increased chances of respiratory distress, and the likelihood of the baby contracting autoimmune diseases and allergic ailments. C-sections also delay mother-newborn bonding and breastfeeding, and increase the chances of repeat caesareans for subsequent deliveries.
Dr Batla says charging the same amount for c-sections and natural deliveries is one way to build trust. “Some hospitals are already doing that to dispel suspicions of medical profiteering,” he adds.