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Birth by the Blade: Unravelling India's Caesarean Conundrum

Introduction 

Caesarean (C-section) rates have been steadily climbing in India, sparking debates and raising concerns among healthcare professionals and policymakers alike. This surge prompts critical examinations into its ramifications on maternal and infant health, healthcare costs, and the sustainability of the healthcare system.


WHO recommends a threshold of 15% as the number of C-sections that should happen for delivering children. India stands at 21.5%, a data higher than the suggested limit and in private hospitals, it hides an even more alarming statistic of a whopping 47.4%. 

A Caesarean birth or a C-section began around the 1940s, a technique that consumed a lot less time and effort of the medical team while also ensuring hearty monetary benefits. 


A painting of live caesarean section

Image credits- Facebook


The historical roots of the Caesarean section extend far into antiquity, appearing in the annals of both Western and non-Western literary traditions. While the term first found its place in obstetrics during the seventeenth century, the early chronicles of this surgical practice remain veiled in mythological narratives. The idea that it originated with the birth of Julius Caesar is refuted by the fact that his mother, Aurelia Cotta, continued to live for a considerable amount of time after that. In ancient epochs, this procedure was exclusively undertaken when the woman was on the brink of death or had already passed, serving as a desperate measure to salvage the unborn child. This trend endured until the nineteenth century when the advent of anaesthesia heralded a transformative era. Subsequent advancements in surgical techniques from the late nineteenth century through the twentieth century have meticulously honed the procedure, yielding diminished morbidity and mortality rates. Consequently, the objectives of Caesarean sections have metamorphosed, shifting from a sole focus on foetal rescue or adherence to cultural and religious norms to a paramount concern for the well-being of both mother and child, all while accommodating the preferences of the mother. 


Corporate Greed

Over the years, the number of private hospitals has increased in India rapidly and the increment in the number of C Section deliveries has unfortunately correlated with this surge.  According to a report published in 2021, more than 47% of the deliveries in private hospitals in India were taking place surgically. 

There are fundamental requirements of time and patience for performing a normal vaginal birth, something that sways away private constitutions from opting for this option. A C-section is done in under an hour, while a vaginal birth can take anywhere from 8 hours to 2 days. Increased medicalisation of childbirth is commercially lucrative and thus a motivator. The math here is simple – a natural birth requires just an overnight stay of the mother at the hospital while a Caesarean warrants 4-5 days of stay plus the expenses incurred at the OT, with the total amount costing eight times as much. Moreover, hospitals are also required to be able to switch to a C-section should the situation ask so.  

Public hospitals often have different priorities, resources, and guidelines compared to private hospitals when it comes to childbirth, including the use of C-sections. They often serve a broader population, including individuals with lower socioeconomic status who may have higher rates of medical complications. Prioritising vaginal deliveries when possible can help reduce the risks associated with surgery and promote better overall health outcomes for both mothers and babies. Some public hospitals prioritise promoting and supporting natural childbirth whenever possible. They may offer comprehensive prenatal education, labor support, and pain management options to empower women to have vaginal deliveries safely. 


The Causes and the Implications 

Economic disparities and the proliferation of private healthcare facilities, particularly in urban locales, exacerbate this trend, as access to such services often correlates with higher C-section rates. Moreover, medico-legal considerations, including fears of litigation and the associated risks may influence healthcare practitioners' decisions towards opting for caesarean deliveries as a precautionary measure. Maternal preferences, influenced by evolving societal perceptions and concerns over labor pain, contribute to a growing demand for elective C-sections. Additionally, the medicalization of childbirth, characterized by a preference for surgical interventions among healthcare providers, further amplifies C-section rates.


The burgeoning prevalence of C-sections in India engenders a spectrum of implications that reverberate across maternal and neonatal health, healthcare economics, and societal equity. Maternal health risks associated with caesarean deliveries, including heightened susceptibility to infections, haemorrhage, and extended recovery periods, underscore the need for cautious consideration of surgical interventions. Furthermore, neonates born via C-sections are susceptible to respiratory complications and long-term health ramifications, warranting careful deliberation on delivery modalities. From an economic standpoint, the escalating costs associated with C-sections strain healthcare resources and pose financial burdens on families, aggravating healthcare inequities. Moreover, their disproportionate distribution across urban-rural and public-private healthcare sectors underscores systemic disparities in access to quality maternity care. 


chaild birth by caesarean section

Image credits- samschroder.co.za


Maternal Healthcare 

Maternity care for childbirth delivery encompasses a range of services including prenatal care, labor and delivery assistance, and postnatal care. It involves monitoring the health of the mother and the developing foetus, providing education and support, managing any complications that may arise during pregnancy and delivery, and ensuring a safe and healthy birth experience for both mother and baby. Maternity care for vaginal or "normal" deliveries and C-sections differs primarily in the method of childbirth and the associated medical procedures.


For vaginal deliveries, maternity care focuses on prenatal education, monitoring the progression of labor, pain management techniques (such as epidurals or natural methods), coaching during labor, and assisting the mother through the pushing stage until delivery. After birth, postnatal care involves monitoring the mother and baby for any complications, providing breastfeeding support, and ensuring both recover well from the delivery. In contrast, maternity care for C-sections involves preoperative evaluation to determine the need for surgery, discussing the procedure with the mother, and obtaining informed consent. During the surgery, medical professionals perform the C-section, usually under regional or general anaesthesia. Postoperatively, maternity care focuses on monitoring the mother's recovery from surgery, managing pain and discomfort, preventing infection at the incision site, and assisting with breastfeeding if desired. Additionally, there may be specific considerations for caring for the newborn, such as assessing their breathing and providing necessary medical interventions.


Dr. Evita Fernandez (obstetrician) from the Fernandez Foundation, talks about the risks involving repeated pregnancies through c-section, “The Second time around, when the woman gets pregnant the risk she faces if she sets into labor and attempts a normal birth is 0.5% risk of the uterus rupturing and previous scar giving way. If there is a third time, the risk of her having, what we call an adherent placenta is very high. The blood vessels penetrate the whole wall of the womb and she could bleed internally, a condition that might prove fatal” (Fernandez Foundation). Medical experts say that there is a higher risk of diseases, pulmonary complications, or respiratory issues in the newborn when the delivery is done through caesarean pre-labor.


While all this is highly unethical and alarming, more importantly, it just no longer lets people place their absolute trust in doctors. The thread of trust here, that the doctor handling them will do their very best seems to get broken, which diminishes the relationship irreversibly.  


The Surge and Other Associated Risks 

The prevalence of C-section deliveries in India has almost tripled in the last 1.5 decades. As per the Ministry of Health and Family Welfare report, there has been an increasing trend of C-sections in the last 3-4 years. More than 60% of births in Telangana are through C-sections. 


Recent studies have highlighted that there might even be a physiological aspect here, linking C-sections to postpartum depression (PPD). PPD is associated with reduced quality of parent-child interaction and adverse effects on maternal and child health. New mothers’ perception of more negative childbirth experiences, such as unplanned/emergency C-sections, are linked to Post Traumatic Stress Disorder (PTSD). 


Medical Ethics Go For A Toss

The principle of patient autonomy, wherein individuals have the right to make informed decisions about their healthcare, may be compromised in contexts where healthcare providers prioritise their own preferences or convenience over those of the patient. This raises questions about the ethical implications of paternalistic decision-making in childbirth practices. The ethical principle of informed consent requires healthcare providers to ensure that patients understand the risks, benefits, and alternatives of medical interventions before providing consent. However, in the case of caesarean deliveries, women may not always receive adequate information or have the opportunity to make informed decisions, leading to concerns about the validity of consent. Healthcare providers have a duty to act in the best interests of their patients (beneficence) and to avoid causing harm (non-maleficence). However, the overuse of caesarean deliveries without medical necessity may expose women and babies to unnecessary risks and complications, raising ethical questions about the balance between beneficence and non-maleficence. The increasing rates of caesarean deliveries in India strain healthcare resources, including personnel, facilities, and financial resources. This raises ethical questions about the equitable allocation of resources and the potential impact on access to maternity care for underserved populations. Ethical healthcare practice requires transparency in decision-making processes and accountability for outcomes. However, in contexts where caesarean deliveries are influenced by economic incentives or medico-legal concerns, there may be a lack of transparency and accountability in decision-making, leading to concerns about professional integrity and trust in the healthcare system.


Conclusion

When there are complications during labor or delivery, such as foetal distress or placental problems, a C-section can be a life-saving procedure for both the mother and the baby. However, the concern is that this option is chosen far more than required. 

The escalating rates of caesarean deliveries in India leave us grappling with a myriad of unanswered questions and a palpable sense of concern. As we navigate this complex landscape, we are confronted with uncertainties regarding the long-term implications for maternal and neonatal health, the sustainability of healthcare systems, and the perpetuation of socio-economic disparities. What are the underlying factors driving this trend, and to what extent do societal norms, economic incentives, and healthcare practices shape childbirth preferences? How do we reconcile the imperative for safe childbirth practices with the realities of limited access to quality maternal healthcare services, particularly in underserved regions? Moreover, what role do policy interventions and community engagement initiatives play in mitigating the burgeoning rates of caesarean deliveries and fostering equitable healthcare access? These questions linger, underscoring the imperative for continued research, dialogue, and collective action to address the complexities surrounding the surge in C-section rates. As we confront this open-ended conundrum, it is incumbent upon stakeholders across healthcare, policy, and advocacy spheres to remain vigilant, fostering a culture of critical inquiry and proactive engagement.

 

By: Sudhansh Gurjar

A second year student at the department of BA programme, Hindu College.

 

References

Maternal and neonatal outcomes associated with cesarean delivery": A study examining the implications of cesarean deliveries on maternal and neonatal health outcomes in India.

National Family Health Survey

"Caesarean Section: Who, When, and Where?" by Sutapa Agrawal, et al. (Journal of Health Management, 2016)

"Explaining the Rapid Increase in India's Caesarean Section Rates: A Quantitative Analysis" by Manoj Mohanan, et al. (Population and Development Review, 2017)

Agrawal, Sutapa, et al. "Caesarean Section: Who, When, and Where?" Journal of Health Management, vol. 18, no. 2, 2016, pp. 255-267.



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