Mumbai: Over the decade upto 2016, the percentage of Caesarean deliveries has doubled in India, as per a report released by The Lancet on October 13, 2018. Going up from 9% to 18.5%, this increase corresponds with the global increment (21%) in C-section deliveries. This pattern is a matter of concern, said the report.

A C-section delivery, as opposed to a normal vaginal delivery, requires incisions in the abdomen and uterus and is viewed as a life-saving procedure for the mother and the child in case of certain complications. These include clinical emergencies that may affect the pregnancy or labour-- foetal distress, prolonged labour, excessive bleeding and high-risk pregnancies with a history of diabetes or HIV.

The Lancet report flags the proliferation of C-sections in private hospitals as the prime driver of this trend. In doing so, it questions the rise in unnecessary C-sections, conducted even when pregnancies are low-risk. Annually, 50% of the 6.4 million unnecessary C-sections around the world were located in Brazil and China.

Avoidable surgical procedures act as long-term impediments to the health of the mother and child and could end in death or disability, WHO had warned in this 2015 statement. An often ignored fact is also the relatively slower process of recovery post a C-section delivery and the trauma it can cause. It also increases the expense burden on the patient and her family.

“The bills went up to more than Rs 1 lakh and now that’s something that we’ll have to consider in case we decide to have a second child,” said Apoorva Panwar(23), who gave birth to her daughter through a C-section in April, 2018.

A first child delivered through a C-section procedure also increases for a woman the likelihood of complications in the next pregnancy, as per a 2014 Lancet report.

In Chandigarh, 98% deliveries through C-section

Is there an acceptable percentage of C-section deliveries? In 1985, WHO had advocated that 10%-15% of deliveries in a country could be through C-section procedures. But in a 2015 statement it clarified that it should be provided to any woman in need. As a country’s C-section rate rose towards 10%, there was a corresponding decline in child and maternal mortality, it said. But there was no evidence of it making an impact on child and maternal mortality after the rate crossed 10%.

If more than 10%-15% of deliveries are conducted through C-section it means overuse and misuse of the procedure, The Lancet report said.

In India, C-section rates vary widely -- it is 6% in Nagaland and Bihar and 58% in Telangana, showed National Family Health Survey-4 (NFHS-4) data. “C-section rates crossing 50% is simply unacceptable,” said Arun Gadre, a Pune-based gynaecologist and senior coordinator for Support for Advocacy and Training for Health Initiatives (SATHI).

The highest number of C sections in the country was reported from Chandigarh (98%), way beyond what Gadre considers acceptable. For every one child born through normal delivery, 60 children were delivered via C-section. In Delhi, the percentage stood at 67.83%.

At 6.1%, south Asia has witnessed the fastest increase in caesarean rates in the last fifteen years, as per the Lancet report.

However, in the sub-continent, India has lower rates than Bangladesh (30.7%) and Sri Lanka (30.5%), but higher rates than Nepal (9.6%) and Pakistan (15.9%).

Private facilities conduct more C-sections: 45% in cities, 38% in villages

Health activists believe that the private section is fuelling the boom in C-sections. “The declining face of public healthcare and the aspiration for better services push families into choosing the private sector,” said Gadre. “This is the basic pathology of Indian healthcare. In the last 14 years, nothing has been done to been done to hold the private sector accountable and unregulated c-section run amok. The private sector is categorically profiteering through C-sections.”

In India, 45% of Caesareans were conducted in urban, private facilities and 38% in rural private facilities. And 56% deliveries in private hospitals empanelled under the Central Government Health Scheme (CGHS) were Caesarean procedures, as per a 2017 reply by JP Nadda, union health minister. Data collected from 20 out of 31 cities (64.5%) with private hospitals empanelled under CGHS were disproportionately inclined towards Caesarean deliveries.

A C-section delivery seems to be the new “normal”, new mothers living in urban India told IndiaSpend. Most women in her office had undergone a C-section, said Reshma Kuckyan (29), who birthed via a C-section when it was found that her baby’s growth was lagging. “My colleagues kept telling me that I would be fine, and since 90% of them had a C-section, I was prepared to have one myself.”

Among cities, Pune recorded the least number of C-sections at 38%, still above the acceptable limit.

C-section deliveries have moved upwards from 28% to 41% in private hospitals between 2005-2006 and 2015-2016. Public facilities, on the other hand, have recorded a decline, as per data in NFHS-4.

Women in wealthiest quintile seek more C-sections

Why are C-sections more common today? Changing dietary habits, late pregnancies and the fear of labour pain are some of the reasons, said doctors.

“I have had mothers with unrealistic expectations insisting on having babies at a specific time,” said Suchitra Pandit, director and consultant obstetrician at Surya group of hospitals, Mumbai. “One patient who was in labour said she wanted to have her baby only at 5pm.”

When she was warned about the dangers of delaying her delivery her family said they were willing to put down the specification in writing.

Among women in the wealthiest quintile (top 20% of the population by income), the choice of undergoing C-sections has gone up from 10% to 30% in the 20 years upto 2014, reported IndiaSpend in 2017.

The increased rate of C-section deliveries also reflects of medical advances that allow detection of emergencies that necessitate it, said doctors. Colour doppler ultrasounds and neonatal intensive care units (NICU) have made it easier for doctors to assess the risks attached to a foetus’ growth.

“The presence of high-capacity NICU in tertiary settings can save the life of many premature babies. If we can salvage a life in times of complications, then we have no choice but do a C-section,” said Pandit.

At 3.5 million, India has the most number of preterm babies in the world, according to WHO.

Keeping a check on numbers

WHO recommends Robson classification, a checklist of 10 obstetric parameters to determine the need for a Caesarean. These include factors such as the history of a pregnancy and gestational age.

In 2017, an online petition signed by more than 1 00,000 people had raised attention to India’s tryst with continually rising rates. The ministry of women and child development pushed for the display of Caesarean numbers by private hospitals, reported The Hindu on July 4, 2017.

“You tend to lose count of the number of deliveries and surgeries you conduct. But when you see the numbers, it acts as a check,” said Seema Jain, a Delhi-based gynaecologist.

(Chhetri is a graduate of Lady Shri Ram College for women.)

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Devyani Chhetri