The caesarean conundrum in India - Both excessive and inadequate use of emergency delivery procedure

As per findings from the National Family Health Survey, while a greater proportion of women are delivering at a hospital or a healthcare institution than two decades ago (at least nine out of every 10 women deliver at a hospital or healthcare centre), caesarean rates have also increased over the years – from 3.2 per cent in 1995-96 to 28.1 per cent as of data from 2017-18.

This share is the highest in private hospitals which handle 29 per cent of institutional births and 63 per cent of all caesarean deliveries. On the other hand, Government hospitals conduct nearly 70 per cent of deliveries and 35 per cent of all c-sections.

Further, c-sections deliveries are more common among the richer sections of the society and in the southern states, with more than half of all births in Telangana being c-section as opposed to states such as Nagaland, where only 5.8 per cent of all births are done through caesarean.

As the survey reveals, India is way above the World Health Organisation (WHO)’s recommendation of the ideal rate for c-sections, which is 10-15 per cent. According to the WHO, when caesarean rates rise towards 10 per cent, the number of maternal and newborn mortality rates decrease, however, when the numbers go above 15 per cent, there is no evidence that mortality rates decline correspondingly.

C-sections as lifesavers

In certain pre-determined cases, or in a medical emergency where vaginal delivery is not possible, caesarean section births are carried out as the risk to the baby or mother through the normal route would be higher. This is especially so if the mother has certain medical conditions such as diabetes or high blood pressure, or has an infection which could pass on to the baby through the birth canal. C-sections may sometimes be recommended if there are twins, triplets or multiple children.

C-sections are also carried out in certain conditions such as cord prolapse where the umbilical cord slips into the vagina before the baby, if the baby is in the breech position, where the baby’s feet are facing down, as opposed to the head, or if the baby has a medical condition which requires early medical intervention.

In certain other conditions, the labour may also not progress, or progress slowly despite the completion of the date, hence, requiring an emergency c-section. Further, if a mother has already had a c-section, any subsequent deliveries may require c-sections, unless a safe vaginal delivery can be carried out.

The dangers of c-section

If c-sections are lifesavers than why is there a concern over it? This is because caesarean deliveries can create complications and have possible side effects. This is especially so in cases where c-sections are carried out as an elective procedure because of maternal demand due to various reasons such as the fear of pain during childbirth, past negative experiences with normal childbirth, fear of excessive blood loss, the incorrect belief that c-sections are healthier and safer or because parents want the child to be born on a particular date.

In certain other cases, hospitals, especially private ones, opt for caesarean procedures for financial reasons. As per a study by IIM Ahmedabad titled, "Too much care? Private health care sector and surgical interventions during childbirth in India," the financial incentives that caesarean deliveries provide, is an important reason behind the higher levels of c-section deliveries in private hospitals. The study quotes data from NFHS when it says that at an average a natural birth at a private healthcare facility costs Rs 10,814 while a c-section costs Rs 23,978. Mothers are also required to spend more days at the hospital post-delivery in the case of a c-section, as opposed to a normal delivery.

The implications of caesarean deliveries are not just financial. As per a 2018 Lancet study, women who electively opt for caesarean sections, especially in the absence of adequate healthcare facilities and skills, could be at a greater risk of maternal or infant mortality. Caesarean deliveries are associated with higher chances of dangerous or fatal conditions such as preterm birth, stillbirth, uterine rupture, and ectopic pregnancy.

Further, the recovery time for caesarean delivery is higher than a normal delivery, and the risk of wound infection or adverse reactions to the anaesthesia is also greater. Mothers are also at a greater risk of facing complications during subsequent pregnancies such as placenta previa, where the placenta partially or totally covers the opening of the cervix.

The IIM A study also details complications that caesarean births can have for the newborn – post-operative care for the mother could lead to delayed breastfeeding, newborns are also more likely to suffer from respiratory problems such as transient tachypnea, a short, self-limited condition characterised by faster breathing and have lower Apgar scores (a score that summarises the health of a newborn – the higher the score, the better the newborn is doing.)

Another study published in the journal Nature also suggests that babies who are delivered through the normal route have a higher concentration of gut bacteria from their mothers, while babies born out of caesarean deliveries have higher concentrations of hospital bacteria. Gut bacteria play a role in various diseases that a person may get during childhood or later on in life.

A dual concern

However, despite having high levels of caesarean births, India faces the dichotomy of having a deficit of life-saving caesarean procedures, among the underprivileged sections of the society, and the overuse of the caesarean mode among the affluent sections.

Experts recommend that in the case where the push for caesarean procedures comes from the mother and the family, doctors and healthcare centres should provide better counselling on the risks associated with it. The state should also ensure better access to healthcare facilities across socioeconomic levels to ensure that all sections of the society have access to such emergency procedures if required.