BackAn open and shut case?
An open and shut case?
Premium(Photoimaging by: Malay Karmakar / Mint)
When Sumita, a 40-year old school teacher, went into labour with her first child, she checked into a 30-bed nursing home near her parents’ home in Kolkata, and nervously braced herself for delivery. The obstetrician announced that while her contractions were progressing normally, she was likely to be in labour for most of the day. Keen on natural birth, Sumita said she was ready to wait.
Labour advanced well. But within two hours, the doctor began to express concern about the fact that Sumita’s blood pressure had risen slightly. Before she could protest, he had told her anxious family that Sumita’s safest bet was a Caesarean section. Less than three hours after she arrived at the nursing home, Sumita was wheeled into the OT.
“I now know I could have waited and had a normal delivery. But, I was so nervous I just did what the doctor said. Later, the other patients told me that obstetricians at that nursing home rarely waited for delivery to take its course—they simply operated right away."
Risky option
Whether physicians are resorting to Caesarean operations more readily, or patients are increasingly opting for the surgery, recent studies suggest that a complex web of societal, technological and commercial factors are spurring more urban Indian women to deliver via surgery, with some hospitals reporting C-section rates as high as 80%. Experts say the trend is troubling as research suggests that Caesareans are risky for both mother and child, and should be performed only when medically needed.
High percentages
The World Health Organization (WHO) estimates that no more than 10-15% of all births should be via C-section. Yet, most countries record far higher Caesarean percentages. The UK reports an average rate of around 25%; in the US, it’s about 30%. In Brazil, where some hospitals report rates as high as 90%, locals joke that the women there deliver naturally only when their doctors are stuck in traffic.
The Union government doesn’t keep track of C-section numbers in the country, but small studies by Jitendra Nagpal, a paediatrician and clinical epidemiologist at the Sitaram Bhartia Institute of Science and Research, Delhi, and others suggest the procedure is widely prevalent in cities, particularly in the arena of private health care.
A study that appeared in the Indian Journal of Community Medicine last year found that in an upper middle-class community in east Delhi, 35% of 419 deliveries over a five-year period were Caesarean births. “We had started with the presumption that it would be on the higher side, but that it would be as high as 35% was quite beyond our comprehension," says lead author Sanjiv Bhasin, a doctor and professor in the department of community medicine at the University College of Medical Sciences, Delhi.
“This high rate cannot be explained by purely obstetric reasons." Percentages also vary on a hospital-to-hospital basis, and can be as high as 70-80%, says Nagpal, who is planning to launch a larger, Delhi-wide study later this year.
‘Convenient’ procedure
Urban Indian women are now marrying later, conceiving later in life, and having fewer children. Every child is so precious that parents are averse to taking any risk and are increasingly viewing the Caesarean as a reliable option. The result is, certain pregnancy-related complications rarely handled surgically in the past—breach babies that have swivelled into an upside down position, for example—are now mandatory C-sections, says Shishta Nadda Basu, head of obstetrics and gynaecology at Delhi’s Jaipur Golden Hospital.
“Heroic obstetrics is simply not practised any more. Previously, delivering a breach baby through natural delivery was no big deal, but I would now be labelled a dangerous doctor if I was doing that," says Basu.
Advances in technology have also made Caesarean sections a generally reliable choice. The operation itself is more fine-tuned now. Surgeons make a horizontal incision lower down in the abdomen rather than cutting vertically from top to bottom. They have also switched to using regional rather than general anaesthesia, further reducing complications, Basu adds.
The burst in numbers is also inextricably linked with the advent of “corporatized" private health care in India.
Birth is big business; delivery rates vary from city to city, but a large private hospital in Delhi can earn up to Rs70,000-80,000 for a Caesarean package (including room and OT charges), whereas a normal delivery package brings in around Rs44,000, according to numbers collected by a team of doctors at Sitaram Bhartia hospital.
Rupak Barua, chief operating officer at the Calcutta Medical Research Institute (which reports an 80% C-section rate), concedes that budgetary pressures do have some influence on the number of Caesareans a hospital performs. But, he maintains that any profit accrued is not really significant after accounting for OT, room and service costs. Rather, the growth in C-section numbers, he says, is better explained by changing urban lifestyles, busy obstetrician schedules and the convenience of planned procedures. “Many women try to schedule Caesarean procedures on special days such as birthdays or festivals," says Barua. On some of these days, women line up for Caesareans," he adds.
There is no denying the fact that Caesarean sections routinely save lives. In the event of certain serious pregnancy-related complications, the surgery can be a mother or baby’s only hope. At least two studies have also shown that scheduled or “elective" C-sections—as opposed to an “emergency" Caesarean section in which a mother or child is already in distress—may even be safer than vaginal deliveries. Some scientists also argue that the procedure can help reduce the risk of problems such as incontinence in later life.
Possible complications
Research, however, challenges these claims, and throws light on the problems that can complicate a surgical birth. Bleeding can be severe and the surgical wound can get infected. Recovery time is weeks longer and more painful. And, after one C-section, a mother faces serious risks during her next delivery, including the chances of uterine rupture or her new baby’s placenta attaching itself to her scar.
Caesareans can also cause problems for the child. In a study reported last December in the British Medical Journal, researchers studied 34,458 live births in Denmark—of these, 2,687 were elective Caesareans—and found that C-section babies were up to four times more likely to have respiratory problems. In the absence of the natural hormonal signals released by labour, new mothers also take longer to lactate, which means that breastfeeding—which should start in the first hour of birth—is often delayed, says Nagpal.
“There is no doubt that a normal vaginal delivery is safer as it is designed to expose the baby to our environment in a controlled and monitored way. If it was better to deliver through the stomach, nature would have surely made it so," he says.
Financial motives
The trend has also raised questions about doctors’ financial motives, but the subject obviously elicits strong reactions in the medical community. “Many people think we don’t have the time to wait for natural delivery (to take its course), or that as doctors we are all out to fleece money via unnecessary operations," says Anjila Aneja, coordinator and senior consultant for obstetrics at Delhi’s Max Super Specialty Hospital. “It is just not like that," she says, adding that she earns the same amount, irrespective of whether she is performing a Caesarean or vaginal delivery. The situation is a lot more murky, however, when it comes to the unregulated and booming arena of small, private nursing homes that have been sprouting steadily in cities across India. Nursing home administrators and doctors contacted by Mint either refused to discuss the issue or maintained that medical factors alone dictated the number of Caesareans they perform. “We’ve got reasonable rates here. It’s got nothing to do with financial incentives," says obstetrician Pushpa Sanghi, owner of Pushpa Maternity and Nursing Home in Hyderabad.
The reality, however, is very different. Nupur Barua, a senior research adviser with the Danish International Development Agency, which is funding a study to monitor the impact of under-the-radar health care facilities—such as less than qualified doctors and resource-poor nursing homes—in three Delhi slums, says that there is a well-oiled nexus in which doctors routinely refer pregnant women to nursing homes for Caesarean sections they may not need.
DIFFERENT VOICES
Advocates of natural childbirth say what is really perpetuating India’s “C-section epidemic" is fear of the experience of natural birth. Apprehensions about labour pain and the inability to control or predict a natural delivery lead at least some urban women to opt for C-section surgery even when it’s not strictly necessary.
“My 40 weeks were up, but my labour pains weren’t starting. So, instead of getting induced, and being in labour for 14-20 hours, I just decided to go for a Caesarean directly," says Debjani Dutt, an architect in Delhi who gave birth to her son last month. “I don’t think I regret it." Others may not have directly requested the procedure, but say they felt relieved when their doctors recommended it.
Smita Barooah, 35, a fine arts photographer in Singapore, who had her first child in Gurgaon, says: “I would have gone in for normal labour if things had progressed as per schedule. But, I have no regrets. In fact, I almost went and kissed my doctor when he told me it would have to be a C-section the first time."
The fear surrounding labour has a lot to do with lack of information and awareness, as well as the ongoing “medicalization" of the birthing experience, says Divya Deswal, 39, a former civil engineer who now works as a childbirth educator and doula in Delhi (a doula is a non-medical assistant who provides physical, emotional and informed choice support in prenatal care, during childbirth and during the post-partum period). “Information on labour and birth has been distorted into being about fear and pain. Women are so scared of going through labour now that they see cutting themselves open as a safer option," says Deswal. The fact that many Indian hospitals do not allow spouses or family members to be with the woman in labour, or the fact that episiotomies—a surgical incision made to enlarge the vagina—are now practically routine, doesn’t help in making mothers feel better about delivering babies the way nature intended, Deswal adds.
As one of a handful of certified doulas in the country, Deswal is part of a growing natural childbirth movement, working to spread awareness among urban women through groups such as Birth India, based in Mumbai, and Bangalore Birth Network, which recently held the country’s first film festival devoted to issues of birth.
“We’ve come to believe that C-sections are safe but it’s an urban myth," says Ruth Malik, 38, who co-founded Birth India, a natural childbirth advocacy group in Mumbai, last year, after having gone through two Caesarean procedures she now believes weren’t necessary. Ruth, who recently filed a suit against her doctor in Mumbai, says: “Birth is not an illness. We don’t need a surgeon to help us have babies. It’s a natural function, it’s something our bodies simply know how to do."
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