C-sections: docs alone to blame?

Years ago, I had read a column about a woman who had sued her obstetrician, feeling ‘robbed’ of her motherhood, because the obstetrician had performed a C-Section on her. A woman in Sydney, meanwhile, was very upset that people not involved in the delivery process (like lawmakers, politicians etc) are discussing this.

Because in her case, she had had a normal delivery — a baby weighing 3.92 kg, who was severely asphyxiated while she had a perineal tear which had caused her a lot of morbidity in the form of incontinence and various other problems. If anyone had told her about the risks of normal delivery, she would have opted for a C-section.

Nearly 14 years ago, Australia went through a lot of debate and many obstetricians were ostracised for performing C-section. Hence, they started issuing a review article to all prospective parents — explaining the benefits of normal delivery including risks and also benefits of C-section including risks.

This was a very balanced article with the explanation that they should discuss it with all stakeholders, including their midwife, come to a final decision and give their consent in writing so that the number of complaints would hopefully come down. This put the onus on the prospective parents.

On August 3, 2018, the Supreme Court of India dismissed a plea seeking the laying down of guidelines for Cesarean deliveries in hospitals, saying the petition was an abuse of process of law. There are a lot of debates about C-section and woman’s rights in several countries — whether a woman has a right to opt for C-section or not? But there has been no consensus on this as several people think that this includes a baby’s right too.

We have had many women delivering babies by breech presentation (where the butt comes out first and the head last) by normal delivery. But lately, the risk of birth asphyxia leading to brain damage is higher and hence most obstetricians nowadays deliver such babies by C-section.

Gestational Diabetes Mellitus (GDM), a lifestyle disease among pregnant women, was very uncommon in the past, but nowadays we see almost 25% to 30% pregnant women being diabetic. Though many women with GDM deliver normally, most others deliver by C-section either because their babies have grown much bigger than their pelvis can accommodate or due to some other complication.

Today, the number of babies being conceived through in-vitro fertilisation (IVF) is increasing by the day, and many parents who have gone through the difficult period of conceiving babies through IVF opt for C-section. Obstetricians, too, deliver these babies though C-section, though medically this is not an indication.

Pre-eclampsia concerns

We used to have eclampsia wards in many hospitals, where women with convulsions during labour/delivery were taken care of. Today, with increasing medical care, eclampsia has been checked. However, a renewed attention is being paid to pre-eclampsia — a dangerous condition with deleterious effects both on the baby and the mother — which could potentially lead to eclampsia. Many women are delivering by C-section during pre-eclampsia to avoid eclampsia.

Last but not the least, the ‘muhurtham’ section. Some women want to deliver at a set date and time, and this is not peculiar to India but is a global problem. A growing number of women in executive positions or even working women don’t want any uncertainty and prefer to deliver at a “right time” and plan their “diary”.

So given all these factors, who decides how women want to deliver versus what is best for them. It is unfair to blame doctors for the increasing number of C-sections. Suffice to say that the decision to deliver babies in a particular way should be taken in conjunction with the prospective parents after having discussed all possibilities and ensuring a safe motherhood and healthy baby.

Maternal and neonatal mortality rates are still high in India. Therefore, we need to have a countrywide audit by using well established March of Dimes criteria for C-sections to evaluate the morbidity and mortality data before we blame doctors or the hospital fraternity. There is a need to account for every mother’s and baby’s death along with the morbidity data. Lastly, one has to take into account the rights of the women and the unborn baby too.

Considering all this, we are in the same position as rest of the world in this debate. The final word is yet to be spoken.

(The writer is chairman and practicing neonatologist, Cloudnine Group of Hospitals)