Abnormal rise in C-sections

Medical ethics: Rate of caesarean sections in pvt hospitals is 41%, way above WHO's 10-15% limit

The commercialisation of caesarean deliveries, especially in private hospitals, hit the headlines recently following an online petition. It was further highlighted when Women and Child Welfare Minister Maneka Gandhi asked the Ministry of Health to ensure that hospitals make public the number of caesarean births. Figures for C-section deliveries are alarming, putting a question mark on the possible unethical practices prevalent in private hospitals. Spotlight dissects the issue.

The latest National Family Health Survey (NFHS) data has brought to light an alarming rise in caesarean sections (C-sections) being performed in the country. The rate of caesarean section (CSR) has doubled in a decade from 8.5% in NFHS-III (2005-06) to 17.2% in the latest NFHS-IV (2015-16).

Further disaggregation of data between public and private health facilities is even more shocking. While there is a decline in CSR for births in public health facilities from 15.2% in NFHS-III to 11.9% in the latest figures, the CSR in private hospitals has increased to 41% as compared to 27.7% in NFHS-III.

The data reveals that a decade ago when only 18% of the institutional births were taking place in public health facilities, CSR for public health facilities was at a higher range of 15.2%, which has now reduced to 12% in spite of the fact that institutional deliveries there have risen to 52%. Whether it’s a good or a bad sign can only be concluded after a thorough analysis of factors which have led to this decline.

However, what is extremely stupefying is the steep rise in CSR in private healthcare facilities. A comparison of NFHS-III and NFHS-IV figures tells us that despite fewer number of institutional births taking place in private health facilities in comparison to public ones, CSR in private facilities is thrice more at 41% than CSR in government hospitals.

Many of us may quickly attribute this wide variation between CSR in public and private health facilities to the poor capacity of public health institutions to manage emergency obstetric cases which shifts the burden to private facilities, and hence a higher CSR there. This interpretation at a glance may sound quite convincing given that we all know the sorry state of government hospitals. However, what needs to be seriously taken into account is that any CSR higher than 10-15% in a region is medically unacceptable as per the World Health Organisation (WHO) guidelines.

A WHO task force on averting maternal mortality after detailed analysis of research conducted in different regions has concluded that while C-sections play an important role in preventing maternal and neonatal mortalities when “medically necessary”, there is no evidence that mortality rates decline if CSR is above 10%.

This means that C-sections which account for 10-15% of CSR are essentially unnecessary, irrespective of whether they happen in public healthcare sector or private. A CSR of 41% in private hospitals far surpasses this threshold. This should certainly ring an alarm not just among the healthcare seekers but also among the health service providers, including the state health departments and the Ministry for Health and Family Welfare.

C-section is a life-saving procedure which is integral to emergency obstetric care and should only be undertaken when there is a perceived risk or threat involved to the life of the pregnant woman or the child if she goes through a natural birth process. Thus, any C-section undertaken with the idea other than preventing maternal or infant morbidity or mortality is unnecessary and should be avoided.

However, there could be several factors which may push one to opt for a C-section even when it is not required. Most of the times the push may come from the obstetrician who is either not sure about his/her judgement or who has an ulterior motive – more profit by misleading and exploiting the patient. While a case of wrong judgement may apply to both public and private sectors, the profit motive essentially applies to private healthcare providers.

There is usually a wide variation in the charges for normal deliveries and C-sections across private hospitals, which may range from a few thousands of rupees for a normal delivery to a few lakhs for C-sections. Apart from the high procedure charges, a C-section also leaves abundant scope for the hospital to extract more money by extending the stay of the patient at the facility and imposing charges for extra medication, investigations and other miscellaneous services.

Since there is no regulation on charges for services at private health facilities, they can shoot up their rates as high as they want. At times, these expenses could be enough to rob one of years of savings or even push a family to below poverty line. It has also been revealed through regional studies that if a woman is covered by health insurance, health facilities would more readily suggest a C-section as the claim amounts are higher.

Are women to blame?
Of late, there have been several reports from different parts of the country where women have become victims of unnecessary C-sections and hysterectomies. In fact, Karnataka Chief Minister Siddaramaiah recently acknowledged the fact and called for strict action against health institutions which undertake unnecessary C-sections.

There’s also a growing argument usually put up by service providers blaming women for this abnormal rise in C-sections. Some women might prefer surgery over natural birth usually out of fear of going through the pain. There are also instances wherein the parents want to plan the birth to schedule it perfectly with an auspicious day or time. However, there are no specific studies which may establish the share of these factors in overall CSR.

Moreover, even in such cases where the woman demands a surgical delivery, the final decision lies with the obstetrician and if the doctor can spend adequate time counselling the woman on ways she can work to make normal delivery a fulfilling experience by getting over tocophobia and explaining both short-term and long-term effects of a C-section on her body and health, the procedure can certainly be avoided.

There’s a greater need to understand factors contributing to the increase in CSR in the country. There is also an urgent need for private healthcare facilities to be brought under strict regulation and monitoring to ensure that unnecessary C-sections (or for that matter any unnecessary procedure) is prevented.

Following standard protocols, such as Robson’s Classification, should be mandatory for public and private healthcare providers to arrive at the decision of carrying out a C-section. Institutions should be mandated to maintain strict records backed by due medical justification for any C-section which they undertake.

The Clinical Establishment Act passed by Parliament but not enforced so far could be a robust instrument in regulating the unchecked spike in C-sections in the country. Beyond all, government hospitals need to be strengthened and better equipped to deliver emergency obstetric care so that people are not forced to depend on private institutions for critical healthcare services.

(The writer is a health activist associated with Prayas Chittorgarh and Jan Swasthya Abhiyan)