High cesarean section rates in the country
The rates of cesarean section deliveries are increasing in the country and there is a perception amongst the public that many of these are unnecessary cesarean sections.
According to a World Health Organization (WHO) report published in 2010, the cesarean section rate in India was 8.5%. The percentage of cesarean section deliveries in the country is 17.2% as per the National Family Health Survey (NFHS)-4 (2015-16) released earlier this year (Press Information Bureau, Ministry of Health and Family Welfare, March 28, 2017). This latest figure is apparently higher than the “ideal” rate between 10% and 15% as that recommended by the WHO in 1985.
The high cesarean rates in the country, as a number, cannot be viewed in isolation.
There are several reasons why a cesarean section delivery may be chosen over a vaginal birth.
There are the medical indications, the absolute and relative indications, because of which a doctor may recommend an elective caesarean section. At times, in conditions such as obstructed labor or other obstetrical emergencies, a caesarean section is done as an emergency procedure, where it is lifesaving for both the mother and the child.
Then there are the non-medical reasons.
The decision to perform a caesarean section is not solely in the hands of the doctor. Patient preferences or caesarean on maternal request also play a part.
Anxiety about vaginal birth, fear of vaginal birth (tocophobia), precious child are some factors which influence the choice of cesarean section by the expectant mother as a mode of delivery, in the absence of any medical or obstetrical contraindication to vaginal birth. Some women want to deliver on an auspicious date or even time. This is another reason why they opt for an elective cesarean.
Cesarean section rates are higher in tertiary institutes or superspecialty hospitals. Similar is the case with senior and experienced doctors, who may not do routine vaginal deliveries. If you take informed consent, then again the cesarean section rates may be higher.
All these non-medical factors contribute to the increase in cesarean section rates. And, while they are not the sole cause, they do need to be taken into account.
Then again it is important to evaluate the correlation between cesarean section rates and the infant mortality rate (IMR) and maternal mortality rate (MMR).
Data from NFHS-4 showed that private hospitals carried out 40.9% cesarean sections, while this rate in government hospitals was 11.9%. The two cannot be compared. It is important to assess the corresponding IMR and MMR.
Many women doctors may choose to have a cesarean section instead of vaginal birth, which also needs to be computed. Unless it can be proved that the cesarean rate in doctors and VIPs is low compared to the general population, it cannot be said that the cesarean rates are unnecessarily high. This is not so.
Cesarean section is a surgical procedure, with potential complications for both the mother and the child. An informed consent needs to be taken before proceeding with the procedure.
The decision of the United Kingdom (UK) Supreme Court in the case of Montgomery v Lanarkshire Health Board was a landmark judgement, which made the patient an active partner in decision making as far as his/her treatment is concerned. It ruled that the doctor has a duty “to ensure that the patient is aware of any material risks involved in any recommended treatment, and of any reasonable alternative or variant treatments”. The doctor has to inform the patient of all possible risks, even though rare, and let the patient take a decision.
The patient should be informed that even elective CS is not risk-free and carries serious risks for mother and child.
An audit of deliveries cesarean sections, in the private as well as public health facilities, is needed to find out the reasons for the decision to perform each cesarean section before judging that economics and not medicine, influence a doctor’s decision to do a cesarean delivery.
Dr KK Aggarwal
National President IMA & HCFI