Articles after articles come (Spike in Caesarian Section deliveries across TS, November 26, The Hans India), using Caesarian Sections to demonize the doctors, especially in the private sector. The oblique suggestion, of course, is greed of the doctors. Without discounting commercial motives, most debates on Caesarian Section rates show a tunnel-vision in understanding the problem. The doctors are only a small part of the whole picture. The above news item declares that private sector has more Caesarian sections than the public sector- 52% of the total 148376 deliveries and 43% of the total 153250 deliveries respectively. Firstly, a simple statistical analysis of the figures in the private and the public sector as quoted does not show any statistical significance at 0.05, 0.01 or even 0.1 levels. So, greed is perhaps not a factor.
The second issue is that Caesarian Section is rising the world over, and India is no exception. Recent statistics from 150 countries shows a global Caesarian Section rate of 18.6% of all births. China stands at 47%, Italy at 36%, Australia at 33%, and United States of America at 32.2% to name a few. Canada, UK, and New Zealand has figures around 26%. Also, the proportion of Caesarian Sections is increasing every year in all countries.
The financial, legal, and technical reasons for such increases are manifold: Increasing maternal age, increased numbers of multiple births, higher rates of obesity and Diabetes among women, medical-led view of pregnancy and birth leading to higher rates of interventions, fear of birth and labour pain, concerns about genital modifications after vaginal delivery, misconception that CS is safer for the baby, the convenience for health professionals and for the mother, fear of medical litigation, belief that Caesarian Section is less traumatic to the baby, low tolerance of anything less than the perfect birth outcome, and so on. Cultural considerations and horoscope considerations also play an important role in specific contexts; common in countries like India and China. The pressure of the best outcome in terms of a healthy baby and mother in an institutional set-up is a major driving factor for increasing CS rates.
There are other reasons too. Polycystic Ovarian Disease (PCOD) in women has grown to epidemic levels. Multiple gestation are very common in these and other patients too undergoing treatment for infertility. In the Indian context, there are theories that Western style commodes, dining tables, and other such habits leading to a lack of usage of squatting position contributes to a narrow pelvis and increased CS rates. Cephalopelvic disproportion (CPD) occurs when a baby’s head or body is too large to fit through the mother’s pelvis. In the previous era, before CS, a mother with severe CPD would undergo difficulties in labour, sometimes even ending in maternal death. Delivery by Caesarian now of such women may be an important factor in transmitting the genetic trait of CPD over generations. The segment of CPD patients may simply be increasing in the population.
Big babies are also an issue as pregnancy sometimes becomes the reason to eat and rest more! Big babies are more difficult to deliver normally, and Caesarian Section becomes the safer route for delivery. There is also a speculation of a trend in society that perinatal mortality or morbidity in the form of complications are acceptable after a CS, but never after a normal delivery. This contributes to a trend towards more CS. Lawyers have sued Obstetricians in the West for astonishing amounts after decades of a normal but prolonged delivery where the child later developed mental abnormalities.
The point is that the reasons for increasing CS rates are complex and goes beyond the simple binary of ‘greed or no greed’ in conducting a CS or a normal delivery respectively. The worry of excessive Caesarian Sections are potential risks and complications to the mother and child apart from the costs involved. Due to the complexity of all these scenarios and the interconnected factors, interventions to reduce unnecessary CS have only shown moderate success to date. Considering solely medical factors in this complex scenario is likely to be a futile effort. Factors associated to women’s fears; and societal and cultural beliefs are very likely contributing to the increase.
The much-quoted World Health Organization figure of 10%-15 % as the ideal Caesarian Section rate needs an Indian perspective as well. Less than 10% implies that the health standards for the country are poor and more than 15% implies unnecessary CS, with risks outweighing benefits. USA has a CS rate around 35%; and in India, the overall rate of Caesarean Section in 2015–16 was around 17.2%. At least in one aspect we seem to be better than the USA, but these figures reflect something else. Despite the obviously evident high Caesarian Section rates above 50% (and sometimes touching 90%) all around in the country, an overall figure of 17% points to pathetic health delivery standards of the country, averaging the country’s figure to such a respectable figure. The Caesarian Section rates must be very low, reflecting a poor healthcare, across a major part of the country. The governments should be highly reflecting about its own performance over decades based on these numbers.
The World Health Organization Statement, reiterated by the Indian Obstetrician’s body FOGSI, emphasize that every effort should be to provide Caesarean Sections to women in need, rather than striving to achieve a specific rate. Decreasing Caesarian Section rates is not simply setting a goal and sticking to it. There needs to be a global shift normalizing vaginal birth and providing the foundations which make it more achievable, such as continuity of care and high-quality independent birth education. FOGSI also recommends the setting up of a registry to collect anonymous data at hospital level using the WHO recommended classification system as the first step in determining the range of Caesarean rates. In the complex scenario, focussing on one aspect is perhaps wrong. Even if charges for normal vaginal delivery become equal to Caesarian Section charges (as some suggest as a solution), it is highly doubtful that such a strategy would reduce the CS surgeries for delivering the baby.
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