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Alarming Rise of Caesarean Section Deliveries

A Case Study of Kulgam

Nadiya Muzaffar (nadiyamuzaffar1@gmail.com) is a doctoral student at the Department of Sociology, Aligarh Muslim University, Aligarh. Mohammad Akram (akram_soc@yahoo.co.in) teaches at the Department of Sociology, Aligarh Muslim University, Aligarh.

The phenomenal increase in institutional births in India has been accompanied by a disturbing rise in caesarean section deliveries. The prevalence of, reasons for, and consequences of c-section deliveries in the town of Kulgam in Jammu and Kashmir are studied. The findings not only reveal an alarmingly high prevalence of c-section deliveries in the town, but also that these deliveries are being largely performed without medical indications, adversely affecting the health of women. In order to monitor and control c-section deliveries in the country, immediate policy interventions are required.

The authors want to thank all the respondents who willingly agreed to share their personal experiences. Thanks are also due to all the surgeons, nurses, ANMs and especially the ASHAs and the staff of government and private hospitals who provided valuable information during the fieldwork. The authors express their gratitude to the anonymous referee for their valuable comments and suggestions.
 

The promotion of institutional delivery by the Government of India is considered an important step to reduce maternal and neonatal mortality. Several government initiatives, including the Janani Suraksha Yojana (JSY), have resulted in phenomenal growth in institutional deliveries. Institutional delivery refers to delivery taking place at a medical institution under the supervision of trained and competent health personnel in order to avert complications or deaths during childbirth. The child can be delivered normally or through a surgical procedure, generally called caesarean section (c-section), wherein the foetus is delivered through an incision in the mother’s abdomen and uterus. There are different kinds of c-sections, namely classical c-section, lower segment c-section (LSCS), caesarean hysterectomy, etc, but the LSCS is the most commonly used procedure today. It is done by making a transverse cut in the peritoneum over the lower segment of the uterus.

Betran et al (2016) analysed the data on c-section rates in 150 countries from 1990 to 2014 and found that 18.6% of all births occur by c-section in these countries. These rates vary from 6% in the least developed countries to 27.2% in the most developed countries. Latin America and the Caribbean region have the highest c-section rates (40.5%), followed by Northern America (32.3%), Oceania (31.1%), Europe (25%), Asia (19.2%), and Africa (7.3%) (Betran et al 2016: 1–12). Although the high or low prevalence of c-section in different countries or regions is caused by different medical and non-medical factors, an important directive from the World Health Organization (WHO) warns against high prevalence of c-section and suggests that “there is no justification for any region to have caesarean section rates higher than 10–15%” (WHO 1985: 436–37). Gibbons et al (2010) have also revealed that the c-section rates above 15% have not shown any additional benefit for the health of mothers and newborns in populations.

When we compare data from the first National Family Health Survey (NHFS-1), conducted in 1992–93, to the fourth NFHS (NHFS-4), which was conducted in 2015–16, we see a rise not only in institutional deliveries but also in c-sections across Indian states, including the state of Jammu and Kashmir. Institutional deliveries across India increased from 26.3% in 1992–93 (IIPS 1995a) to 78.9% in 2015–16 (IIPS 2017a) and c-section deliveries rose from 2.9% (IIPS 1995a) to 17.2% (IIPS 2017a). The proportion of deliveries by c-section was more than twice as high in urban areas (28.3%) than in rural areas (12.9%) (IIPS 2017a). In Jammu and Kashmir specifically, institutional deliveries increased substantially from 22.4% (IIPS 1995b) to 85.7% (IIPS 2017b) and c-section deliveries rose from 4.3% (IIPS 1995b) to 33.1% (IIPS 2017b). The rural areas in Jammu and Kashmir have 26.9% c-section deliveries and for urban areas it is higher, that is 53.1% (IIPS 2017b).

However, the figures related to c-section deliveries do not reveal whether these were carried out for medical reasons or other reasons. Though the increasing prevalence of c-section deliveries is alarming, it is yet to be noticed by the government as well as people. Several studies have reported a statistically significant increase in maternal health complications such as anaesthesia accidents, haemorrhaging, bladder and bowel injury, hysterectomy, infectious morbidity, etc, in c-section cases as compared to planned vaginal deliveries (Oski 1994; Schiff et al 1996; Irion et al 1998). Studies have also shown that women who deliver through c-section take longer to recover and have a lower satisfaction with their birth experience (Pai 2000; Kuklina 2009; Weisman 2010). These evidences suggest that the high prevalence of c-section deliveries in any population enhances women’s health vulnerabilities and, hence, checks and balances need to be instituted to prevent unnecessary surgeries from being carried out.

In a welfare state like India, the responsibility of protecting the interests of people, especially the vulnerable sections, rests with the state. The state needs to be more vigilant and open to make “evidence-based and conscientious assessment of the health achievements” (Akram 2014a: 40), so that it can make necessary improvements in its health policies and introduce course corrections in its health programmes. Such evidence-based course correction is not possible without an in-depth analysis of the ground realities. However, there is a dearth of primary data-based studies with regard to the causes and consequences of LSCS in India, including the state of Jammu and Kashmir. This study attempts to fill up this gap.

Research Methodology

The study focuses on pregnant women residing in the town of Kulgam. This town was chosen because one of the authors belongs to this town and was concerned about the rising trend of the c-section deliveries there. Also, no study analysing this phenomenon in the area had been conducted. The fieldwork was carried out over a period of eight months, that is, from May 2016 to January 2017. The study uses exploratory research design and employs the case study method to focus on the social actors’ accounts. The sample size comprised all the pregnant women of the town of Kulgam who had their first antenatal check-up in either April, May, or June 2016. The study uses in-depth interviews with the identified pregnant women, health professionals (doctors, staff nurses, gynaecology ward in-charge) who work in the Government District Hospital, Kulgam (GDHK) and auxiliary nurse midwives (ANMs) and accredited social health activists (ASHAs) workers who deal with the pregnant ladies of the town.

All the respondents (pregnant women) were located with the help of 15 ASHA workers assigned to the 13 wards of Kulgam. The municipal committee of Kulgam has 13 wards, covering almost 40 mohallas. Forty-one pregnant women who had undergone their first antenatal check-up in either April, May, or June 2016 and were registered with the ASHAs were identified. Out of these 41 women, four were not present in the town during the fieldwork, one had to terminate her pregnancy after the initial four months, and one did not agree to participate, leaving a total of 35 respondents to be included in this study. Incidentally, all the respondents were Muslim women and informed consent was obtained from each one of them. Their deliveries were classified as normal, involving episiotomy, and LSCS.

In addition to the interviews, the records maintained by the GDHK and National Rural Health Mission (NRHM) at the block and district levels on antenatal care (ANC) services, pregnancy, and delivery outcomes in Kulgam were analysed. Therefore, a methodological triangulation was used to get a more detailed and balanced picture of the situation.

High Prevalence of LSCS

The interviews with the 35 respondents revealed that 19 women (54.3%) delivered through LSCS, 11 women (31.4%) had a normal delivery, and the remaining five (14.2%) underwent episiotomy while giving birth. Out of the 19 LSCS deliveries, 12 were performed at the GDHK, five in private institutions, and two referrals delivered at the government-run Lal Ded Hospital in Srinagar. Out of the 11 normal deliveries, 10 took place at the GDHK and one was a normal home delivery. Out of the five episiotomies carried out, three were done at the GDHK and two were referred to Mirza Mohd Afzal Beigh Memorial Maternity and Child Care Hospital (MCH), Anantnag.

Further, the records of 369 in-patients registered with the gynaecology department of the GDHK for the month of April 2016 were analysed. Out of the 369 patients, 263 had delivered at the hospital—83 through LSCS (31.5%) and 180 through normal deliveries (68.4%). Of the remaining patients, 43 cases were kept under observation, 35 were abortion/miscarriage cases, and 40 were referred to the MCH in Anantnag.

These figures also imply that there is a high prevalence of LSCS deliveries in Kulgam district. The rates range between 31% for Kulgam district (rural as well as urban) (GDHK records)1 and 54% for the town of Kulgam, an urban area where the fieldwork was carried out. The LSCS rates for the town of Kulgam are very high when we compare them to the norms prescribed by WHO (1985) (as mentioned earlier) and even with the c-section rates prevalent at the national level.

Reasons for High Prevalence

The International Federation of Gynaecology and Obstetrics (FIGO 2007), an organisation that brings together professional societies of obstetricians and gynaecologists of more than 130 countries on a global basis, states that

surgical intervention without a medical rationale falls outside the bounds of best professional practice. Caesarean delivery should be undertaken only when indicated to enhance the well-being of mothers and babies and improve outcomes.

However, the findings of our study reveal that amidst the huge prevalence of LSCS there were only a few cases in which the respondents could identify valid medical grounds for their LSCS delivery.

Medical reasons for LSCS delivery: The respondents who identified medical reasons for LSCS are—Shaziya,2 a 22-year-old young woman, who delivered her second child at the GDHK, faced acute foetal distress and, hence, delivered through LSCS; Sabiha, a 34-year-old woman, delivered her third child at a private hospital in Anantnag district through LSCS because of her previous two LSCS deliveries; Foziya, a 34-year-old woman, delivered her second child through LSCS at a private hospital in Srinagar district as she suffered from gestational diabetes and high blood pressure throughout her pregnancy; Ishrat, a 35-year-old woman, was referred by the doctors at the GDHK to the Lal Ded Hospital, Srinagar where she delivered her third child through an emergency LSCS because of her high blood pressure condition; Iffat, a 29-year-old woman, delivered her first child through LSCS because the foetus was in the transverse lie position; and Shabnam, a 30-year-old woman, suffered from pre-eclampsia and gave birth to her first child through LSCS at the GDHK. In all these cases, the respondents were convinced that there was a medical rationale behind the LSCS delivery.

Other reasons: The majority of the respondents identified reasons other than evidence-based medical complications as an immediate cause of LSCS delivery.

During the fieldwork, some pregnant women provided accounts where they felt that they were dictated to by the surgeons by virtue of the medical knowledge and power that they possessed. Abida, a 26-year-old woman, gave birth to her first child at the GDHK through LSCS. While talking about the reason for her LSCS delivery, she said,

When I reached the GDHK, I was told to get admitted. The doctor told us that my child had ingested poop (meconium) inside the womb. The doctor there did not wait for the delivery to happen normally, although my labour pains had begun. They neither put me on drip nor did they examine me physically. We could not understand what was happening, nor could we question the doctor. One feared to do so, because after all the doctors know better. After the birth of the child it was seen that the baby was fine and had not ingested any poop.

Mehnaza, a 26-year-old woman, gave birth to her first child through LSCS at the GDHK. She said,

My baby had almost reached the vagina but the surgeon pushed my belly from the top and my baby rotated and lay in a transverse position, and it became difficult for the baby to come out through the vaginal opening. The surgeon, therefore, performed LSCS. The surgeon later said that the vaginal opening was too narrow for the baby to pass through as I was very young.

Thus, the decisions or preferences of the surgeons are hardly questioned by the patients because of the perceived supremacy of the doctors, and the patients are left with no option but to comply. Ann Oakley has blamed the medicalised system for not taking into account women’s preferences and experiences (Turner 2006). Michel Foucault has also emphasised the use of medical knowledge as a means of social control and regulation (Akram 2014b).

At the GDHK, there is a paucity of surgeons and non-availability of 24×7 obstetric services in the gynaecology department. When asked about the shortage of manpower, a staff nurse in the gynaecology department replied that there were only two lady doctors, three assistant surgeons and five nurses in the department. She said, “The bed strength is very low—only 15 beds for double the number of patients. There is a dire scarcity of staff, and the patients are too many.” The staff nurse further added that

Out of the six working days, each gynaecologist sees outpatients for three days and conducts surgeries on three days. They examine almost 300 to 350 outpatients a day and remain very busy; besides this, they perform five to six LSCSs on a surgery day and sometimes even more.

Consequences of High LSCS Rate

The government hospitals often do not provide an environment conducive for letting the labour progress naturally. The surgeons do not want to be in the hospital after four o’clock in the afternoon. Hence, they sometimes find it more convenient to deliver through LSCS rather than wait for the labour to progress naturally and deliver babies later in the evening or at night. Simran, a 30-year-old woman, got admitted to the GDHK at 3:00 pm for her first delivery. There she was asked to give a written consent for the LSCS as the doctor would not be available after 4:00 pm. She said, “I did not want to unnecessarily undergo LSCS and wanted to deliver normally. So, I did not agree for a LSCS.” She was admitted on the condition that if her pains intensified during the night she would be referred to Lal Ded Hospital, Srinagar. She feared for her own safety and the safety of her child and left the district hospital at 6:00 pm and got the c-section done at a private hospital.

The non-availability of surgeons after 4:00 pm at the GDHK also forces the women who are admitted for their delivery to demand LSCS in order to avert any unforeseen situation where they might be referred to hospitals in Anantnag or Srinagar districts. When a gynaecologist working at the GDHK was asked about the high prevalence of caesarean deliveries, she said, “C-section is done on demand; 50% patients and their attendants demand for c-section because of fear of getting referred to other hospitals, which takes place due to the lack of surgeons after 4:00 pm in the hospital.”

The overcrowded gynaecological out-patients department at the district hospital pushes many women to go to private medical clinics and maternity hospitals where c-sections are being carried out rampantly at a high cost. All the five respondents who went to private hospitals had LSCS deliveries. Nighat, a 36-year-old woman, who had delivered her second child at the GDHK through an LSCS, preferred going to a private doctor for her third delivery rather than to a government hospital “because of the fear of crowds and long waiting hours.” Jameela, who delivered at a private hospital, said, “The doctors at the GDHK do not examine the patients as keenly and carefully as do the doctors in a private hospital.” Nida, a 29-year-old who delivered her first child at a private hospital through LSCS, said, “The doctors at private hospitals are more careful in observing the patient unlike the doctors at government hospitals who see the patient for the sake of God, that is, very carelessly.”

The expression “too posh to push” was coined over 14 years ago to describe the maternal request for a c-section in the absence of clinical indications (Weaver and Magill-Cuerden 2013). Though this expression does apply to some cases, it did not apply to most respondents interviewed. In fact, there was only one woman who said that she could not bear the pain experienced during a normal childbirth, so she talked to her surgeon and delivered through LSCS. Nighat, who delivered her second child through LSCS, said, “I told the doctor that I am not strong enough to bear labour pains, and I want to have the delivery through LSCS.”

The GDHK fails to provide ambulance services to pregnant women at the time of delivery. Shubi, a 33-year-old woman, who delivered her second child through LSCS at GDHK, went into labour in the middle of the night and had no car to take her to the hospital. So, she went on a two-wheeler with her husband to the GDHK, which was just a kilometre away. She said, It was because of the lack of the ambulance facility that I had to go on a scooter. Because of this, the foetus in the womb moved upwards and the fluid inside also reduced making it difficult for the baby to descend. So, LSCS was carried out.”

Both the National Health Policy of 1983, 2002 and even 2017 do not contain any provisions for the regulation of LSCS deliveries. The rate of LSCS deliveries both at public and private hospitals are soaring unchecked and LSCS deliveries are often carried out without medical justifications. In the case of private maternity hospitals in the Kashmir Valley, the institutional deliveries have become synonymous with caesarean deliveries. According to some feminist accounts, doctors are exercising their rising influence to redefine childbirth “as a dangerous, pathological event, to denigrate and eliminate midwives, and to fuel the perception that middle- and upper-class women were less able to withstand the challenges of childbirth” (Beckett 2005: 253).

The c-section was introduced as a life-saving procedure to be undertaken when the medical reasons called for it. However, the massive prevalence of LSCS beyond medical reasons has had an adverse impact on the health of the women and the newborns.

Most of the women who underwent LSCS in the town of Kulgam complained of wound infection during the postpartum period. Many of them had pus oozing from the incision site and a few complained of abdominal pain and fever during the postpartum period. Sabiha, when asked if she faced any complication after her LSCS delivery, said, “I bathed after 40 days of my LSCS delivery because of some moisture oozing continuously from the site of surgery.” Another respondent, Shabnam, also said, “One of my stitches, even after 20 days of my LSCS, oozed a pus-like fluid, and I could not bathe for 25 days after the delivery.” Mehnaza too suffered from the wound infection in the postpartum period. She said,My incision site was infected, and I had to go to the GDHK to get the wound dressed up till it was completely healed.”

Also, if a woman delivers her first child through LSCS, it is likely that she will have to undergo the same procedure for all her subsequent deliveries. In this study, all three respondents Shoki, a 35-year-old woman, Sabiha and Foziya who had previously delivered through LSCS underwent the surgical procedure again for their next delivery.

The natural/normal and medicalised/caesarean childbirth has an impact on the way the woman thinks of her body. The increased medicalisation of the natural birthing process results in the disempowerment of women. Under the strict supervision of an expert and as a patient whose status is subjugated within an institutional set-up, a woman does not sufficiently use her bodily strength and knowledge. The medicalised childbirth develops some sort of distancing from her own body and lets the doctor take the lead in handling the outcomes. During a LSCS delivery, the woman conceptualises her body as a machine (Garcia et al 1990) to be worked on by the surgeon, and the surgeons as per their convenience might opt for the surgical process over the natural one.

A normal delivery is comparatively much cheaper than a LSCS delivery. According to this study, in a private maternity hospital, the LSCS costs as much as ₹ 40,000. Foziya, who delivered through LSCS at a private institution in Srinagar, belonged to a high-income family. When asked about the total cost incurred during her LSCS she said, The LSCS cost us ₹ 40,000 excluding the money that was spent on the diagnostics and biochemical examinations.” Sabiha who also came from a well-off family had her LSCS done at a private hospital. She said, “The total cost on my LSCS delivery was ₹ 30,000. Besides, I had to undergo the ultrasound sonography (USG) and other diagnostic tests separately from private clinics. It too cost me ₹ 3,000.” Nida who delivered at a private hospital in Anantnag also spent ₹ 30,000 for the surgical procedure. In addition to this, she had to get the USG done at a private clinic which cost her ₹ 2,000. In Jammu and Kashmir, the average out-of-pocket expenditure per delivery in a public health facility is ₹ 4,192 (NFHS-4). As per the National Sample Survey Office (NSSO 2015) report, the average total medical expenditure per childbirth in a public hospital is ₹ 1,587 for rural and ₹ 2,117 for urban areas whereas in a private hospital it
is ₹ 14,778 for rural areas and ₹ 20,328 for urban areas.

Conclusions and Suggestions

The government needs to scrutinise institutional deliveries to ensure that safe and ethical practices are followed during deliveries. This is important because with the increased utilisation of institutional delivery services, the proportion of c-section deliveries has also risen. The high prevalence of LSCS needs to be lowered through policy interventions. The government should ensure that c-sections are not carried out for non-medical reasons. This will lead to improved maternal and child health outcomes, empowerment of women, and reduction of expenditure on health.

To achieve these objectives, the government has to take certain corrective measures. It is essential to increase the manpower and bed strength at government hospitals on a large scale to deal with the problems of overcrowding and overburdening of medical care providers. The central as well as state governments need to prepare a database on the number of c-section deliveries carried out for reasons other than medical. The government and private hospitals/clinics should be specifically monitored by competent and legal authorities to avoid unnecessary c-sections. During ANC, women should be made aware of the benefits of a normal delivery. It is urgent that the healthcare providers are educated about the potential risks of c-sections when carried out in the absence of medical indications.

We recommend looking back to the Alma Ata Declaration (1978) on primary healthcare to provide comprehensive healthcare to all and avoid over-medicalisation of pregnancy without compromising with the necessary goals of institutional and safe delivery. There
is an immediate need for making specific provisions in the National Health Policy and related programmes such as the JSY to regulate and control unnecessary LSCS.

Notes

1 The gynaecology ward in-charge at the GDHK maintains a register for each month, where the activities related to in-patients, birth outcomes, type of delivery, referrals, abortion cases, etc, are recorded. As per these records, the LSCS rate was calculated to be 31.5%.

2 The names of all the respondents have been changed and pseudonyms have been used to conceal their identity.

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Updated On : 17th Jun, 2019

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