Ground situation: separating fact from fiction

As the number of caesarean deliveries rise alarmingly, particularly in private healthcare facilities, a section of doctors claim that they are performing surgical deliveries because of pressure from the patient’s family, a claim denied by health activists and researchers.

Sudha C P, who heads the Obstetrics and Gynaecology Department at the Kempegowda Institute of Medical Sciences, Bengaluru, said it was usually the patient’s attenders who insist on C-section for the woman. “They (family) say they are unable to see the pain of the mother and insist that we conduct C-sections. We counsel such families and dissuade them. We usually see patients from mid socio-economic strata. Such demands are higher in the upper economic strata,” said Sudha.

Lifestyle plays a key role. “We see a lot of obese mothers. They also come with co-morbidity issues such as diabetes and hypertension. In such cases, the child cannot withstand the stress of a normal delivery. We are forced to conduct caesarean,” Sudha added.

Sriprada Vinekar, a consulting gynaecologist at Cloudnine Hospital (headquartered in Bengaluru), said there is a rise in C-sections compared to the situation three years ago as patients mostly avoid the “risk” of a normal delivery. Suhas Pingle, former member of the Maharashtra Medical Council, said: “In society as a whole, the tolerance for pain has gone down. Besides, there is an element of family planning. The child is precious and no one would like anything to go wrong.”

The doctors, however, get little support from public health campaigners with research showing how C-sections are carried out for more profit as the procedure involves a longer stay at the hospital. The National Family Health Survey (NFHS)-IV data supports this theory with statistics demonstrating very high numbers of caesarean deliveries in the private sector.

“Caesarean deliveries have become a business. The hospitals and doctors are making money off unsuspecting women and pushing them towards surgical deliveries,” said Subarna Ghosh, a Mumbai-based journalist-cum-researcher who is associated with Birth India.

India’s C-section rate is growing exponentially. Hospitals and doctors are indiscriminately conducting C-sections to make more money as surgical procedures cost more. Only if women are made aware of the C-section rates of different hospitals and maternity homes, they can choose their hospitals carefully.

It was Subarna’s February petition that triggered a chain reaction. The petition reached Women and Child Development Minister Maneka Gandhi, who wrote to Health Minister J P Nadda. The health ministry then asked the state governments to take steps to curb the menace.

In Telangana, which recorded the highest percentage of caesarean deliveries, an emergency meeting was convened on February 28 by state Health Minister C Laxma Reddy, who warned hospitals against needless surgeries. A hospital in Mahabubnagar was seized and instructions were given to all government and private hospitals to submit monthly reports of caesarean surgeries to the Health Department for scrutiny.

While Karimnagar, Warangal and Nalgonda districts account for 83-80% of unnecessary C-sections, the semi-urban Rangareddy district surrounding Hyderabad recorded 75% caesarean deliveries, the city itself stood at 72%. The numbers in public hospitals, however, are far less as seen from the NFHS-IV data.

In the government-run Bangalore Medical College and Research Institute, not many women insist on Caesarean deliveries. Sunanda Bai, a professor of obstetrics and gynaecology, said, “Very few women tell us that they can’t bear the pain. On counselling, they are convinced. Only if the baby is big, C-sections are planned ahead.”

Bai explained that complications are five times higher in a C-section. Besides, while 350-500 ml blood is lost during normal deliveries, it is around 1-1.5 litres in C-sections, she added. Also, C-section cases would need five days of hospitalisation as against 48 hours for a normal delivery.

Nexus exists
There is a nexus between doctors and hospitals, though barely anyone admits to it on record. The manager of a private hospital near Kolkata acknowledged the link between doctors of a sub-divisional hospital and the owners of the surrounding nursing homes and private hospitals.

“Two patients informed me that the doctor of the government hospital told them they needed C-section and proper facility was unavailable there. So they must go to the Calcutta Medical College, which is 45 km away, or get admitted at a nearby nursing home chosen by the doctor. According to the manager, the sub-divisional hospital is dirty and the dais (midwives) and nurses in the hospitals often behave rudely with the patients, particularly during labour pain. These well-known facts discourage the patients to go to government hospitals,” said Shewli Shabnam, a researcher from Jawaharlal Nehru University, New Delhi, who presented a paper on unnecessary C-sections in an international conference.

“In developed countries, painless vaginal delivery is the most common delivery procedure but in India, the facility of painless labour is not available or extremely rare. There is a dearth of anaesthetists and other manpower for conducting this type of delivery,” said Shabnam, currently working as an assistant professor in a Kolkata college. Often the doctors fall prey to the parental demand of choosing astrologically significant days like Janmashtami to justify caesarean deliveries.

The rapid socio-economic change during the last 25 years have added many new facets to the problem. “It wasn’t unusual for a woman to bear 7-8 or even 10 children, particularly in rural areas. Deliveries were conducted at home and losing an occasional child was accepted. Things have changed. One child is the norm and two definitely is the limit,” said Vivek Sheth, a doctor from the Raigad district of Maharashtra, while justifying the trend.

(With inputs from Kalyan Ray, Mrityunjay Bose, J B S Umanadh and Reshma Ravishanker)