A fifty percent increase in caesarean sections in the Dewas district of Madhya Pradesh has caused alarm and prompted state health minister Tulsiram Silawat to commission an investigation.
The reported rise was described by the minister as ‘objectionable’. According to World Health Organization (WHO) guidelines, c-sections should not account for more than fifteen percent of total deliveries. As such, the spike reported in Dewas’s private hospital has raised red flags, motivating the minister’s direction to the district’s Chief Medical and Health Officer (CMHO) to investigate and discover the causes.
The move by Silawat has been welcomed by the Indore chapter of the Federation of Obstetric and Gynaecological Societies of India (FOGSI). Indore-based OB/GYN Dr Mukta Jain noted “we don’t have internal audit committee that comprises senior gynaecologists and health officers to keep tab on C-section cases.”
As such, Dr. Jain added, “the health minister’s instructions to CMHO Dewas to conduct probe…is expected to reveal causes that can help us take appropriate steps to prevent surgical procedure.”
“In India, a worrying trend has been observed in recent years: growing numbers of unnecessary c-sections”
C-sections are procedures is where surgery is used to deliver infants. In some cases, c-sections are necessary, such as if vaginal delivery would endanger the health of the mother or child. However, in India, a worrying trend has been observed in recent years: growing numbers of unnecessary c-sections.
The reports from the Dewas district is a microcosmal reflection of a much broader national problem. Reports indicate that profiteering in the private sector is to blame for the rise. In just one year, private hospitals performed 900,000 unnecessary c-sections according to a study conducted last year by the Indian Institute of Management in Ahmedabad. In rural India, as many as thirty percent of c-sections performed are unnecessary.
The number of c-sections performed in India has been rising steadily in recent years. In the last 25 years, the number of caesarean sections being performed in India increased sevenfold. In 1992-93 period, just 2.6 percent of births in India were delivered via c-section. By 2015-16, this figure had jumped to 18.1 percent.
A national average of eighteen percent is not much higher than the WHO benchmark. However, there are wild disparities between states. In Telangana, for example, 58 percent of births between 2011 and 2016 were caesarean deliveries. Of these, just 23 percent were emergency deliveries done out of necessity.
The last decade alone witnessed almost a doubling of women undergoing c-sections. Almost seventeen percent of women of women underwent C-sections in 2015-16, compared to just nine percent in 2005-06. In private hospitals, c-sections account for as many as fifty percent of deliveries.
“The rise in the number of unnecessary c-sections has been blamed on profiteering…[leading] to accusations of a racket pushing women into c-sections they do not need and may not want”
The rise in the number of unnecessary c-sections has been blamed on profiteering in the private sector. Caesarean sections cost between two and five times as much as vaginal delivery in a private hospital. This has led to accusations of a racket pushing women into c-sections they do not need and may not want.
Some, however, suggest that profiteering may not be wholly to blame. Researchers in the United States have said that ‘system factors’ play a significant role. These include limited resources and high workload, which can influence doctors to opt for c-sections as they are quicker than vaginal births. This is borne out by statistics. India suffers from shortages of many specialist medical positions, including a shortfall of 76.7 percent when it comes to obstetricians and gynaecologists.
Some doctors have also claimed that it is often a matter of misguided patient preference. Women may request c-sections in the mistaken belief that c-sections are safer than vaginal births. This is not true. As with any major surgical procedure, c-sections carry the risk of complications. In addition, they can cause complications in future pregnancies.
“No matter the cause, it is clear that more needs to be done to promote accountability…[and] some hospitals are bucking the trend”
No matter the cause, it is clear that more needs to be done to promote accountability of doctors performing unnecessary c-sections and investigate reasons why. This has led to controversial proposals such as one by Union Minister for Women and Child Development Maneka Gandhi, who opined that it should be mandatory for hospitals to make public the number of c-sections they perform.
Some hospitals are bucking the trend. At the Sitaram Bhartia hospital in Delhi, caesarean deliveries once accounted for 78 percent of births. By taking steps such as recruiting consultants to make sure doctors were not overworked, training nurses in midwifery and counselling expecting mothers about the myths surrounding c-sections, the hospital cut its rate of caesarean deliveries to eighteen percent of births. While still above the WHO benchmark, it is nonetheless a remarkable turnaround.
Promoting accountability and transparency when it comes to caesarean deliveries is vital if the situation is to be addressed. Ensuring patients are aware and educated when it comes to c-sections is also of great importance. Fundamentally, it is a good sign that c-sections can be accessed when they are needed. But the risks of overuse of the procedure cannot be discounted – and must be addressed.