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Rising Caesarean Births

A Growing Concern

Prashant Kumar Singh (prashants.geo@gmail.com) is Max Planck-India Fellow, Max Planck Institute for Demographic Research, Germany and teaches at the Department of Policy Studies, TERI University, New Delhi. Rajesh Kumar Rai (rajesh.iips28@gmail.com) is Senior Research Scientist, Society for Health and Demographic Surveillance, West Bengal. Shalini Singh (shalinisingh.icmr@gmail.com) is Scientist, ‘E’, Division of Reproductive Biology and Maternal Health, Indian Council of Medical Research, New Delhi. Lucky Singh (lucky.5bhu@gmail.com) is Scientist, ‘C’, National Institute of Medical Statistics, Indian Council of Medical Research, New Delhi.

India’s rising rate of caesarean births is a cause for concern and signals the need for strategies to deal with it. Adverse outcomes of caesarean births include high risk of maternal and neonatal death, various maternal morbidities including infections, need for blood transfusion, neonatal morbidities related to iatrogenic prematurity, and potential complications in subsequent pregnancies.

ACaesarean section (CS) is a significant development of modern medicine and is a life-saving surgical procedure when certain complications arise during pregnancy and labour. However, the growing practice of CS without a medical indication or following demand by the patient has not brought any benefit to the women or infants. Adverse outcomes of CS include high risk of maternal and neonatal death, various maternal morbidities, including infections, need for blood transfusion, neonatal morbidities often related to iatrogenic prematurity; and potential complications in subsequent pregnancies (Roberts and Nippita 2015; Lumbiganon et al 2010). Empirical studies have demonstrated that children born by CS have higher probability of developing respiratory problems, diabetes and obesity later in life as compared to children born via vaginal delivery (Blustein and Liu 2015). India is no exception, where a rising rate of caesarean births has been reported. Using statistics from the National Family Health Survey (NFHS) data collected in 2005–06 and 2015–16, this article presents changes (during 2005–16) in the trend of caesarean births in India, stratified by the place of residence (rural/urban) and by the type of service provider (public/private). Challenges behind the rising caesarean births have been discussed.

Trends in Caesarean Births

In 1985, an interdisciplinary conference on appropriate technology for birth unanimously accepted a 10%–15% caesarean section rate at community level as reasonable to assist women to deliver safely in the face of complications (World Health Organization 1985). Yet, the CS rates have been increasing worldwide (World Health Organization 2015). In 1990, roughly one in 15 babies was born via CS, which has increased to one in five babies in 2014. The lowest rates of CS are found in Africa (7.3%), followed by Asia (19.2%) and the highest rates are found in Latin America (40.5%), and this is coupled with considerable disparity between and within nations (Betrán et al 2016). According to the World Health Organization (WHO) estimates, in the year 2008, the highest proportion of unnecessary CS deliveries were performed in China (32%), followed by Brazil (15%) and the United States (11%) (Gibbons et al 2010).

India has witnessed an increase of 102% in caesarean deliveries during the last one decade—from 8.5% in 2005–06 to 17.2% in 2015–16. Although the current (2015–16) rate of CS is marginally higher than the acceptable range defined by the WHO, there is a need to unmask the huge geographic disparities that exist in its distribution (Table 1, p 23). For example, the statewise data from the NFHS (International Institute for Population Sciences 2017) indicate that the CS rate is highest in Telangana (58%) and lowest in Bihar (6%). Twenty states recorded CS rates higher than 15%, and the trend during 2005–15 indicates that the CS rate has doubled in 16 states. A sharp urban–rural divide in CS rates is also evident from Table 1 (p 23). The caesarean section rate in urban areas was estimated to be higher than their rural counterparts by 34% in Tripura, followed by 26% in Assam and 18% in West Bengal and Manipur. This could be attributed to the fact that the availability of caesarean section facilities is relatively higher in urban areas than in rural settings.

The difference in CS rate by type of service provider is another key dimension. Overall, the CS rate is lower in public health facilities than in private health facilities (Table 2, p 23). The highest CS rate was registered in a private health facility in Telangana and Jammu and Kashmir (75%), followed by Tripura (74%), West Bengal (71%) and Andhra Pradesh (57%). In a few states the CS rates in public health facilities were higher than the national average—Telangana (41%), Jammu and Kashmir (35%), Kerala (31%), Tamil Nadu and Andhra Pradesh (26%). An analysis of these trends revealed that during 2005–16, the CS rate in public health facilities had declined but an increase was observed in the case of private health facilities across many states.

Challenges and Implications

A rapid increase in CS rate and a significant disparity between place of residence and type of provider were evident across many states. However, it is difficult to gauge how much could be attributed to unnecessary CS, including patients’ demand. To researchers, programme and policymakers, it is important to have the process of decision-making for CS mapped out in order to pinpoint the reasons for the unequal growth in rates of caesarean births.

Decision-making is the most important component of caesarean birth; at times, the doctor might leave the decision to the patient to have a caesarean as she might want to have her baby in a particular way or on a particular day (Lumbiganon et al 2010). In India, a very small section of women choose to have CS, being cognisant of the fact that vaginal delivery is an option. This phenomenon is termed as “too posh to push” which is prevalent among educated, rich and urban women who want to avoid labour pain during childbirth and are convinced that CS is safer, faster and less likely to affect the quality of sexual life than vaginal birth (Hopkins et al 2004). A cross-sectional population-based study in Nepal, Bangladesh and India indicates that increased CS rates in the private sector may be driven by interaction of individual-level and provider-level factors as they serve urban, highly educated and economically well-off strata (Neuman et al 2014; Radha et al 2015). Programme and policymakers might not be concerned with this group of women as they have made a conscious choice for CS.

But what if a woman lives in rural India and does not receive the recommended antenatal care or counselling for pregnancy, which is generally the case. The general profile of rural women is that they are uneducated, lack awareness and come from a low socio-economic strata of society, do not have any decision-making power about having a baby, and the low age at conception worsens the situation. In such cases, physicians play a crucial role as they have to decide whether it should be a vaginal delivery or CS. This opportunity gives physicians a window to convert vaginal delivery to CS, as a CS procedure will enhance the physicians’ income or time spent in patient care. The fact that referring patients from a government hospital to a private facility for CS can earn commission for government doctors has also been reported. In some contexts, convenience factors and the threat of medical malpractice lawsuits create incentives for providers to choose caesareans over vaginal delivery (Mishra and Ramanathan 2002).

The Rashtriya Swasthya Bima Yojana (RSBY), a public-funded national health insurance scheme, also covers CS. In some states in India, there seems to be a bias towards surgical procedures; the usage of the RSBY for CS was more than that for normal deliveries, indicating monetary benefit for the private healthcare provider (Nandi et al 2016; Selvaraj and Karan 2012). To stem this moneymaking process that misuses the RSBY by converting vaginal delivery to CS seems difficult. If the patient is not covered under any financial protection scheme, the high out-of-pocket expenditure for unnecessary CS induced by physicians could lead to financial strain for the underprivileged.

For the Indian healthcare system, the key challenge is to identify the balance between providing adequate and high-quality care without performing unnecessary interventions. For instance, a low caesarean rate is associated with a high maternal and newborn mortality and can indicate lack of access to life-saving resources. On the other hand, a very high caesarean rate can be a sign of over-intervention and a trend of medicalisation of birth. It can pose a threat not only to the health of mothers and children, but also to health systems. There is a clear indication of a rising trend of caesarean births in India. The distinction between necessary and excess CS rate is difficult to determine; it requires creation of good databases with record of indications, short and long-term morbidity and partiality patterns of women undergoing caesarean section and their newborns both from private and public providers.

The Indian health system must focus on strategies to strengthen the health systems, including increasing the doctor–population ratio, placing highly skilled and well-trained midwives in labour rooms, allowing birth companions during labour and delivery, providing for painless delivery options, improving labour room infrastructure such as bed, electronic foetal monitoring system, neonatal intensive care units and blood transfusion facility. It is necessary to develop a rating system for hospitals, which considers caesarean sections performed without medical indication as one of the rating components, and also promotes efforts towards popularising natural childbirth. Hospitals and communities should promote health education among women of reproductive age and counsel pregnant women about delivery process. More in-depth research is needed to examine the effects of caesarean section rates on maternal and perinatal morbidity, paediatric outcomes, and psychological or social well-being in the Indian context.

References

Betrán, Ana Pilar, Jianfeng Ye, Anne-Beth Moller, Jun Zhang, A Metin Gülmezoglu and Maria Regina Torloni (2016): “The Increasing Trend in Caesarean Section Rates: Global, Regional and National Estimates: 1990–2014,” PloS one 11, No 2, e0148343.

Blustein, Jan and Jianmeng Liu (2015): “Time to Consider the Risks of Caesarean Delivery for Long Term Child Health,” BMJ: British Medical Journal, 350.

Gibbons, Luz, José M Belizán, Jeremy A Lauer, Ana P Betrán, Mario Merialdi and Fernando Althabe (2010): “The Global Numbers and Costs of Additionally Needed and Unnecessary Caesarean Sections Performed Per Year: Overuse as a Barrier to Universal Coverage,” World Health Report, 30, pp 1–31.

Hopkins, Sue, Lesley Chivers, Chris Bassett and Mike Lehane (2004): “Too Posh to Push,” Nursing Standard, 18, No 35, pp 22–23.

International Institute for Population Sciences (2017): National Family Health Survey 2014–15, IIPS, Mumbai.

Lumbiganon, Pisake, Malinee Laopaiboon, A Metin Gülmezoglu, João Paulo Souza, Surasak Taneepanichskul, Pang Ruyan, Deepika Eranjanie Attygalle et al (2010): “Method of Delivery and Pregnancy Outcomes in Asia: The WHO Global Survey On Maternal and Perinatal Health 2007–08,” Lancet, 375, No 9713, pp 490–99.

Mishra, U S and Mala Ramanathan (2002): “Delivery-related Complications and Determinants of Caesarean Section Rates in India,” Health Policy and Planning, 17, No 1, pp 90–98.

Nandi, Sulakshana, Rajib Dasgupta, Samir Garg, Dipa Sinha, Sangeeta Sahu and Reeti Mahobe (2016): “Uncovering Coverage: Utilisation of the Universal Health Insurance Scheme, Chhattisgarh by Women in Slums of Raipur,” Indian Journal of Gender Studies, 23, No 1, pp 43–68.

Neuman, Melissa, Glyn Alcock, Kishwar Azad, Abdul Kuddus, David Osrin, Neena Shah More and Nirmala Nair et al (2014): “Prevalence and Determinants of Caesarean Section in Private and Public Health Facilities in Underserved South Asian Communities: Cross-Sectional Analysis of Data from Bangladesh, India and Nepal,” BMJ open, 4, No 12, e005982.

Radha, K, G Prameela Devi and P A Chandrasekharan (2015): “Study on Rising Trends of Caesarean Section (C-Section): A Bio-Sociological Effect,” IOSR Journal of Dental and Medical Sciences (IOSR–JDMS), 1, No 14, pp 10–13.

Roberts, Christine L and Tanya A Nippita (2015): “International Caesarean Section Rates: The Rising Tide,” Lancet Global Health, 3, No 5, e241–42.

Selvaraj, Sakthivel and Anup K Karan (2012): “Why Publicly-Financed Health Insurance Schemes Are Ineffective in Providing Financial Risk Protection,” Economic & Political Weekly, 47, No 11, pp 61–68.

World Health Organization (1985): “Appropriate Technology for Birth,” Lancet, 2.

— (2015): “WHO Statement on Caesarean Section Rates,” Department of Reproductive Health and Research, World Health Organization, Geneva.

Updated On : 6th Jul, 2018

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