Cut and open
31 March 2017
The different avatars of surgical births across India.
(This is an essay from our March 2016 print quarterly, ‘At the Cost of Health’. See more from the issue here.)
R, an expecting mother, began seeing an obstetrician early into her pregnancy. On the day of delivery as her lower body was anaesthetised. The doctor made a quick first incision on the wall of her abdomen followed by a second incision on the wall of her uterus. The baby was pulled out, the umbilical cord cut, the placenta removed and the incisions stitched up.
R is one of the 20,54,669 women who underwent a Caesarean section (C-section) operation in India in 2014-15.
Attribute it to sedentary lifestyle, an inclination towards auspicious dates, medicalisation of birthing, or the profit factor for obstetricians, C-sections are becoming an obsession in India and some are calling it an ‘epidemic’. “Around 30 years ago, when I started my medical practice, I didn’t hesitate before attempting a vaginal birth during a breech (when the baby’s buttocks or legs are delivered first) or a low-weight baby or a woman with a history of miscarriages. Today, I would go for a Caesarean. Neither the families nor the doctors are willing to risk it,” shares Dr T Ramani Devi, President, Trichy Obstetrical and Gynaecological Society, who calls the C-section “a protective practice”.
When the national level statistics for C-sections are taken into consideration, it appears that the country is doing fine. With the overall C-section rates of 15.4 percent (2014-15), India is just over the threshold (10-15 percent) prescribed by World Health Organisation (WHO). However, the disparity across the 36 states and union territories, and even within them, speaks a different story.
According to data from the Ministry of Health and Family Welfare (MoHFW), 25 states have recorded a total C-section rate of more than 15 percent in 2014-15. The total rates combine the deliveries which took place at both public institutions and private ones. During the same period, 14 states saw 25 percent or more C-sections. The rate of surgical delivery seemed to be higher when the woman was admitted to a private hospital. For instance, in private hospitals of Tripura only 26 percent of deliveries were vaginal births in 2015-16.
Tripura accompanies nine other states that have over 50 percent C-section deliveries in private institutions (which is more than three times the threshold stipulated by WHO): Jammu and Kashmir (82), West Bengal (68), Telangana (67), Tamil Nadu (59), Bihar (59), Delhi (56), Assam (53), Sikkim (53), and Manipur (52). In India, the 15 percent threshold is inadequate to gauge the situation as 30 out of 36 states and union territories recorded C-section rates above the advised limit, almost normalising the anomaly. Among the remaining states, Gujarat, Uttar Pradesh and Uttarakhand have recorded rates of 9, 10 and 14.9 per cent respectively in private institutions and this data was not available for Andaman and Nicobar Islands, Chandigarh and Lakshadweep.
Although there is no study on how many pregnant women with complications access private hospitals, data from rural areas show that the overall figure of C-section operations is way higher in private hospitals. Barring Dadra & Nagar Haveli and Karnataka, almost every state with C-section rates more than 15 percent in private hospitals have a common factor: shortfall of obstetricians and gynaecologists at Community Health Centres (CHCs), which provide specialised healthcare services to the rural population. ‘Rural Health Statistics of 2012’ from National Health Mission reported a shortfall of 65 percent in obstetricians and gynaecologists at CHCs across India. By March 2015 the shortfall escalated to 76 percent.
Attribute it to sedentary lifestyle, an inclination towards auspicious dates, medicalisation of birthing, or the profit factor for obstetricians, C-sections are becoming an obsession in India.
“You will always find vacancies at government hospitals because recruiting of staff is irregular and outsourcing does not help much. People do not come to government hospitals as long as they can afford private healthcare,” says Dr Pidakala Shyam Sundar, Secretary, Andhra Pradesh Government Doctors Association.
For instance, Madhya Pradesh, which has a whopping 84 percent shortage of obstetricians and gynaecologists in CHCs, has a rate of 38 percent C-sections at private institutions as opposed to four percent at public ones in rural areas, according to the National Family Health Survey 2015-2016 data. Incidentally, institutional deliveries climbed up from 26 in 2005-2006 to 81 per cent in the state in the same period.
Tripura, Manipur, Mizoran and Sikkim recorded 100 percent shortfall in obstetricians and gynaecologists in CHCs. In Tripura, while the percentage of institutional births has gone up from 47 to 80, NFHS-4 data reveals that surgical birth rate in public institutions has dropped from 24 percent in 2005-06 to 18 percent in 2015-16, but shows a four percent rise in private hospitals.
The C-section rates have been climbing in government hospitals too as public institutions in over 19 states have crossed the upper limit of the prescribed range. In April 2015, around 30 government hospitals across Telangana received memos from the government for crossing the 50 percent-mark for C-section deliveries. “Most of the complicated cases are referrals from rural areas. Many cases come at a time when Caesarean remains to be the only option left for us,” says a doctor from one of those hospitals which got a memo.
While money is supposed to be a major driver for C-sections in private institutions, in understaffed government hospitals with many patients, time is a major factor, as doctors are forced to take recourse to Caesarean section to cut down on the time spent on a normal delivery, Dr Achanta Vivekananda, former head, department of gynaecology and obstetrics of Kakatiya Medical College, Warangal, told the Economic Times.
An Indian Council of Medical Research (ICMR) taskforce study was taken up at 30 government medical colleges across India and data was recorded for eight months in 2005-2006. The results showed that only three out of 30 colleges maintained C-sections within the WHO norm. Also, over 42 percent of the women who came for delivery were from rural areas, again underlining the glaring lack of facilities in the hinterland.
The study highlighted the problem of repeat C-sections – when the first surgical delivery leads to Caesarean sections in subsequent pregnancies – and put forth vaginal birth after C-section (VBAC) as a step to bring down surgical birth rates. The study, in its introduction, said “that VBAC offers distinct advantages over repeat caesarean section, since the operative morbidity and mortality are completely eliminated; the hospital stay is much reduced and the expenses involved are much less. The rate of caesarean section surgeries can be reduced by resorting to a trial of vaginal delivery after previous caesarean section, which is safe for the foetus.”
Delivery on chosen muhurat (auspicious time) has become a fad now. If not the auspicious date, it would be some other favourite date of the family.
However, the study found out that “even though the successful VBAC is considered safer than routine repeat caesarean section, the enthusiasm for VBAC is found to be decreasing now due to several reasons.” The fact that many women demand for repeat elective caesarean section in order to avoid a painful natural birth was attributed to inadequate patient information
The other side
The opposite end of the spectrum is equally stark even if there are fewer states in it. Lower C-section rates are often accompanied with poor access to health services and lack of infrastructure, often indicated by a high Maternal Mortality Rate (MMR). A WHO report states that studies show that “when Caesarean section rates rise towards 10 percent across a population, the number of maternal and newborn deaths decreases.” It corroborates with the fact that five of the six states that have C-section rates lower than 10 percent also have high MMR. Bihar, with the lowest overall C-section rate of 0.9 percent, is followed by Uttar Pradesh (3.8), Jharkhand (7), Rajasthan (8.6), Gujarat (8.7), and Madhya Pradesh (8.8).
Except Gujarat, the other four states exhibit maternal mortality rates (MMR) much higher than the national average of 178. While C-section rate is just one of the parameters that can lower MMR, surgical interventions during complicated births can substantially help the numbers go down. In December 2014, noting that most of the designated FRUs (First Referral Units) are not able to provide basic emergency obstetric care due to the shortage of resources, in order to bring down MMR, the government took a policy decision to involve general surgeons to perform C-sections at public health facilities after rigorous training. The impact is yet to be studied.
As medical, monetary and infrastructural factors combine with sociological ones to impact the choice of birth, the conundrum becomes more complicated to unravel. Three successive National Family Health Surveys (1992-93, 1998-99, 2005-06) show that education, wealth and place of residence do contribute to the chances of a woman giving births surgically. NFHS-3 data showed that women who have completed their higher education have higher rates of having C-sections (36 percent) compared to those who have had no education (2.5 percent). The share of surgical births has increased alarmingly amongst the women with higher education: from 16 percent in 1992-93 to 36 percent in 2005-06.
A similar trend can be found when numbers are divided into wealth quintiles (dividing the population into five equal groups as per wealth). In the quintile with the highest wealth, the share of C-sections has increased from 8.5 percent in 1992-93 to 26.6 percent in 2005-06. The data during the same period for the lowest wealth quintile showed a nominal increase from 0.5 percent to 1.8, indicating lack of access to surgical deliveries.
This indicates economic status of the woman played a significant role. Also, it is not just the money or education which are the driving factors, place of residence too plays an equally important role. Urban areas see higher rates as compared to the rural ones. However, with C-section rates in public institutions (where profit factor does not play a role) rising alarmingly as well, it would be interesting to see what the numbers stand at in the NFHS-4 data, which is yet to be published in its entirety.
Doctors point out that keeping C-sections well within the optimal rate in urban areas is increasingly becoming impossible because of many other factors too: couples in cities are getting married late which leads to delayed pregnancies, higher obesity and body mass index, increasing the number of cases of gestational diabetes and hypertension during pregnancy. “Take for instance the increasing incidence of infertility which has, in turn, increased the number of IVF pregnancies. In such cases, it is not just patients and the families, but the doctors too, who are paranoid about the complications and hence choose to go for C-sections,” says Dr Kedar Marathe, gynaecologist and obstetrician from Pune.
Apparently frivolous reasons like auspicious time of birth are also contributing to the rising numbers. “Delivery on chosen muhurat (auspicious time) is a fad now. If not the auspicious date, it would be some other favourite date of the family,” says Dr Ramani Devi of Trichy. There are at least half a dozen websites which figures out an auspicious time for the birth of the child for a fee ranging between INR 1000-5000 (USD 14-75). Adding to all these factors is the fear of urban patients suing them when complications arise, says Dr Marathe.
However, even though the incidences of complications in surgery have gone down over time, a Caesarean section might cause infections, blood-clots, heavy bleeding, delay in weight loss and several other minor and major risks, which a woman needs to know before making an informed decision. While the ‘Standard treatment guidelines in obstetrics and gynaecology’ of MoHFW does list “informed consent” for Caesarean surgery as a preoperative procedure to be followed, there is no way to ensure that this is practised on ground. “When I was pregnant for the first time, I was told there is slightly less amniotic fluid, but I was never told I might have to undergo a surgery. It was only two weeks before the due date that my doctor announced he will do the surgery as soon as possible because the baby will be at risk,” shares Sirisha Ajmera, a mother of two who was not briefed about the problems she or the baby might develop afterwards.
While there are no definitive studies on the purported profits from Caesarean deliveries in private institutions, money has been said to be one of the factors that influence the choice of doctors. Interactions with over 20 women from cities across the country show that cost of a C-section operation can be anywhere between INR 30,000-400,000 (USD 451 – 6025) in a private hospital in India.
The role of midwives has emerged as one of the important factors to promote vaginal birth.
When asked whether putting a cap on the charge for these operations will help in reducing the number, Abhishek Bhartia, Director, Sitaram Bhartia Institute of Science and Research in New Delhi, states, “It is wrongly assumed that money is the primary driver.” This is a view he shares with Dr Marathe, who says, “Many doctors would agree to the fact that they won’t mind charging less for a C-section because it relieves one of the tension creeping up during the long wait for a normal delivery.” According to him, to keep up with solo practices in a system which has a dire lack of trained midwives to support normal delivery (doctors are trained to intervene, not support normal labour), doctors take advantage of the lack of transparency. “Absence of evidence-based training in medical colleges is also one of the reasons,” he adds.
Time for intervention
Like in most countries, in India, there is no governing body or method to audit unnecessary C-sections. In April 2015 WHO proposed adopting of the Robson Classification, which classifies all women admitted for delivery into one of 10 groups based on characteristics that are easily identifiable, such as the number of previous pregnancies, whether the baby comes head first, gestational age, previous uterine scars, the number of foetuses and how labour started.
In a study carried out in 2011 by Pondicherry Institute of Medical Science, Robson’s Classification was used to analyse C-sections at the hospital. The analyses pointed out that women with previous C-section formed 40 percent of the total surgical births. This was similar to the observation made in other studies across India. According to a study done by researcher Sanjivani A Wanjari in Maharashtra, repeat Caesarean section accounted for 33 percent of all operated deliveries.
While adopting Robson’s Classification will clearly provide useful insights into the increasing surgical births, it is easier said than done. “I would recommend by starting with transparency – all hospitals and individual consultants should be required to disclose their Caesarean rates – and force a certain degree of accountability on the part of hospitals and consultants,” said Bhartia. The Sitaram Bhartia Institute had a C-section rate of 52 percent in 2011 after which the hospital took up reform measures and brought down the rate to 32 per cent in 2014-15 and the team intends to bring it down further.
The hospital now encourages group practice, which involves more than one obstetrician managing patients so that at least one of them is always available to assist the patient, and midwifery. The doctors took up interventions in antenatal education of families about eating healthy, exercising, not gaining much weight, and counselling them about benefits of vaginal birth over surgical interventions.
The role of midwives has emerged as one of the important factors to promote vaginal birth. “Midwives are trained to manage uncomplicated pregnancies. The midwifery model of care has been proven to lower maternal and neonatal mortality and morbidity,” says Lina Duncan, who was trained in the US and started the Mumbai Midwife organisationwhere she and her team operate a natural, home and water birth facility, one of the many alternative options slowly gaining popularity in India. A 2014 Lancet study concluded that the researchers identified “more than 50 short-term, medium-term, and long-term outcomes that could be improved by care within the scope of midwifery”, apart from reduced maternal and neonatal mortality and morbidity, reduced stillbirth and preterm birth.
Although there are still very few practitioners and takers of natural birth, non-surgical techniques and a relaxed approach is catching up. Such natural birthing institutes patient intake is usually less than five-six a month so as to ensure that comprehensive care is provided to the mother and child. Through antenatal consultations, personalised and specialised care, availability of doctors in the comforts of home, the clinics are offering a different model of care.
“It is sometimes the case that the doctor did not witness a natural birth in their training, which means they are inexperienced about allowing the process to carry out in its own time without interventions, or letting a woman adapt to her own positions of choice in labour and in birth,” said Duncan.
Birth India, a natural childbirth advocacy group, has started listing out the care providers from across the country who are taking up hypno-birth, doula service (a companion for a birthing mother, and her partner /family), natural birth and other alternatives.
Policymakers are in the process of forming an independent model of care for midwifery practice in India. In 2015, MoHFW held deliberations with representatives from state government and received recommendations to increase autonomy of Nurse Practitioners in Midwifery (NPM). The Ministry had also asked stakeholders to send suggestions on giving clinical autonomy to NPM. One of the key suggestions was that states may consider the option of replacing doctors or addressing the shortage of doctors through deployment of NPMs, especially at delivery points. “As soon as possible, India should reintroduce the midwifery model, which has been completely neglected. Creating a new class of midwives who are trained, knowledgeable and efficient is imperative to bring down surgical births,” says Dr Veda Simons, a specialist in natural and water birth.
At the policymaking level, there is a lot of informal and formal pressure on policymakers that deters the initiation of a mandate to curb the C-section rates at private hospitals, according to Dileep Mavalankar, Director, Indian Institute of Public Health, Gandhinagar. In resource-deficit rural areas, policies which mandate that only obstetricians/gynaecologists can perform Caesarean section can be detrimental, he argues. According to him, political influence is used to keep it this way. Mavalankar argues that general surgeons should be trained and allowed to handle these. “Also, a lot of scientific thinking is required to make a policy effective, but most often it is people from non-specialised backgrounds who make the decisions”. He also emphasises that the government should never incentivise surgical and vaginal births differently; there should be a flat rate for both types of deliveries and the motive of earning more money will no longer exist, he points out. “Good training should be imparted to practice forceps births and vacuum extraction technique, which can cut down C-section rates. Also, techniques to reduce pain during vaginal birth should be popularised,” suggests Mavalankar.
From life saving surgery to a defence mechanism pandering to the perceived risks, the C-section problem of India doesn’t have a one-point solution. In fact, India has come a long way from fearing a cut down under to treating the surgery as a mild inconvenience. The high number Caesarean sections are not normal and an urgent and comprehensive intervention is the need of the hour.
~Ayesha Minhaz is a Hyderabad-based independent journalist who has written for Scroll, Agence France-Presse and The News Minute, among others.