The rate of caesarean sections (or c-sections) is on the rise worldwide, according to data which found that such procedures now account for more than one-fifth of childbirths. The research further postulates that, by 2030, c-sections may account for almost one-third of childbirths as numbers increase.
It is important to note that a c-section can be a life-saving procedure. As the World Health Organization (WHO) points out, “caesarean sections can be essential in situations such as prolonged or obstructed labour, foetal distress, or because the baby is presenting in an abnormal position.” But c-sections are not a tool to be used in the absence of medical necessity.
Director of the WHO’s Department of Sexual and Reproductive Health and Research and the UN Joint Programme HRP Dr Ian Askew explains that “caesarean sections are absolutely critical to save lives in situations where vaginal deliveries would pose risks, so all health systems must ensure timely access for all women when needed. But not all the caesarean sections carried out at the moment are needed for medical reasons. Unnecessary surgical procedures can be harmful, both for a woman and her baby.”
India is no stranger to unnecessary c-sections. As Health Issues India reported in December 2019, “caesarean sections…can be the difference between life and death for some mothers. However, a concerning trend in unnecessary c-sections is being witnessed throughout India – and a recent report from Madhya Pradesh about such practices is raising alarm bells in the state. The Central Bureau of Health Intelligence (CBHI) under the Union Ministry of Health and Family Welfare reports that, in Madhya Pradesh, private hospitals are conducting ostensibly unnecessary c-sections at an alarming rate. One in every two pregnant women underwent delivery by c-sections in private institutions, compared to one in twenty in government-run facilities.”
We noted that WHO guidelines stipulate that c-sections ought not to exceed ten to fifteen percent of all deliveries. As the findings from Madhya Pradesh showed, there is a striking disparity between the number of c-sections performed in privately-run institutions compared to those which are government-run. As we noted at the time
“The National Family Health Survey (NFHS) pegged the proportion of births by c-section to be 40.9 percent in private hospitals, compared to 11.9 percent in government-run hospitals. In India, childbirth has previously been referred to as “a moneymaking racket, with caesarean sections pushed by unscrupulous medical practitioners in search of profit. Healthy young women who could easily have had normal, natural deliveries are lied to, told that they and their babies are at risk, and advised to have invasive surgery. Worried families feel helpless and afraid to refuse doctors’ orders. Thousands of women in even the smallest towns are put through this ordeal for no medical reason at all.” Indeed, c-sections cost between two and five times as much as vaginal births.
“Other factors include a desire by families to undergo c-sections down to personal preference or lifestyle factors such as their age and weight. As such, it would be misleading to claim that all doctors who perform unnecessary c-sections are motivated by profit. Nonetheless, the ostensible overuse of c-sections is a concerning trend and efforts ought to be undertaken to identify the factors driving it. Madhya Pradesh is far from alone in having a high rate of unnecessary c-sections. It is a pan-Indian problem and requires a considered and effective response in order to be addressed.”
Families bear an extraordinary financial burden due to unnecessary c-sections. As Rema Nagarajan reported for Times News Network, “excessive caesarean deliveries in private hospitals could be costing Indian families over Rs 5,000 crore extra every year. This sobering conclusion emerges from an analysis of data compiled from three official reports released recently by the Sample Registration System, the Civil Registration System and the National Statistical Office (NSO).
“An analysis of the data reveals that 28.5 lakh more caesarean sections were done in private hospitals across the country in 2018 than the acceptable international ratio of normal to caesarean births. The average extra cost of each such procedure comes to about Rs 18,000. This means that the 28.5 lakh extra caesarean deliveries cost a total of Rs 5,130 crore.”
Earlier this year, according to Republic World, the Centre formulated “an expert team to examine the state-wise findings of surgical procedures and informed the Parliament that there is an enormous rise of C-sections in private hospitals on Tuesday, as per reports. In response to a question, the Union Health Ministry said that an expert committee was constituted in December to examine the state-wise findings related to C-sections.”
This came after reports last year found that, whilst encouragingly now at least nine in ten women deliver children in a healthcare facility, almost one in three deliver via c-section. This, as The Hindustan Times points out, “is a rate twice of what the international health care community considers ideal…Personal preferences and older mothers are part reason for this, as is, in some cases, profiteering , but another reason, experts say, is that health care workers do not have the time, patience, or inclination to wait.”
One study pegged the number of pregnant women who do not medically require a c-section but undergo the procedure regardless at one in five. This is concerning because, as Askew highlighted, “unnecessary surgical procedures can be harmful, both for a woman and her baby.” As the WHO pointed out, complications “include the potential for heavy bleeding or infection, slower recovery times after childbirth, delays in establishing breastfeeding and skin-to-skin contact, and increased likelihood of complications in future pregnancies.”
Something has to change. HRP and WHO medical officer Dr Ana Pilar Betran stresses that “it’s important for all women to be able to talk to healthcare providers and be part of the decision making on their birth, receiving adequate information including the risks and benefits. Emotional support is a critical aspect of quality care throughout pregnancy and childbirth.”
The WHO further recommends “education interventions that engage women in planning for their birth…use of evidence-based clinical guidelines, performing regular audits of caesarean section practices in health facilities, and providing timely feedback to health professionals about the findings; [and] requirement for a second medical opinion for a caesarean section decision in settings where this is possible.” These need to be taken onboard.
As research published by the British Medical Journal stresses, “in the absence of global effective interventions to revert the trend, Southern Asia and sub-Saharan Africa will face a complex scenario with morbidity and mortality associated with the unmet need, the unsafe provision of CS and with the concomitant overuse of the surgical procedure which drains resources and adds avoidable morbidity and mortality. If the Sustainable Development Goals are to be achieved, comprehensively addressing the CS issue is a global priority.”
India can take steps. As one study points out, “it is feasible to substantially reduce [the] CS rate in [a] private healthcare setting of a middle-income country like India. Ideas such as moving to full-time attachment of consultants, joining a collaborative, improving labour ward support, providing resources for data collection, and perseverance could be adopted by other hospitals in their own journey of moving towards a medically justifiable CS rate.” Investing in midwifery, neonatal and maternal health, nursing, and other healthcare disciplines are also steps which can be taken to reverse a trend of unnecessary c-sections, diversion of resources to where they are not needed, and ensure that those who medically require a c-section can get one.
