The Rising Tide of C-section Deliveries in India: Causes, Consequences, and Solutions
By Arunima Rajan
We delve into the complex and often contentious issue of C-section delivery in India. From the factors driving the rise in C-section rates to the challenges and disparities in access and outcomes, HE aims to provide a comprehensive and nuanced understanding of this critical topic.
As the world's most common surgery, C-section delivery has saved countless lives and improved the health of mothers and new-borns around the globe. But in India, the rising tide of C-section deliveries has sparked a heated debate about the risks, benefits, and underlying causes of this common surgical procedure.
Current Rates and Trends of C-Section Delivery in India
NFHS 5 (conducted in 2020-21) showed that the national C-section rate was 21.5 per cent, higher than what the WHO terms “ideal” i.e. 10-15%. The number had also increased since NFHS 4 (conducted in 2015-16) where it stood at 17.2%.
Dr Kavitha Kovi, a OB-GYN consultant at Aster Women and Children’s Hospital, points out that the upward trend in C-section deliveries is alarming, as the numbers have almost doubled in the last ten years. “Factors like fear of pain and late marriages are the key reasons behind this rise,” explains Kovi.
To combat this burgeoning issue, Kovi noted several measures being implemented by the hospital, including:
Avoiding unnecessary inductions
Educating patients
Alleviating the fear of normal delivery
Encouraging natural delivery process in all OPD consultations
Regular dietary and exercise advice
Providing analgesia during labour
According to Nirmala Chandrashekar, Consultant Obstetrics Gynaecology at BGS Gleneagles Global Hospital in Bengaluru, the factors that contribute to the increasing C-section rates from a doctor's perspective are:
Identifying high-risk foetuses before term (37 weeks of gestation)
Identifying high-risk mothers
The increasing trend of late conception (beyond a woman's age of 30)
The increased diagnosis of a distressed baby during pregnancy
Fear of litigation.
“In our organisation, pregnant mothers are educated about epidural anaesthesia, which makes labour painless. Regular antenatal care is given, and the mother is taught exercises which help with normal delivery,” she adds.
Measures Adopted by Aster
At Aster Women and Children Hospital in Whitefield, doctors encourage all expectant mothers to go with the natural process and only opt for the C-section in unavoidable circumstances. The gynaecology team takes extensive measures to educate and encourage women to undergo a normal delivery and ensure that expecting mothers are confident and empowered with immense knowledge about the safety of vaginal birth and instrumental deliveries. The journey is made more comfortable for mothers by allowing the family to stay with the mother throughout the process.
Proper diet, counselling, and regular exercise are recommended to encourage easy vaginal births. Strict guidelines and protocols are followed in the labour ward to avoid unnecessary C-sections. Regular ANC classes and tours of hospital facilities are also conducted to instil confidence.
Monthly meetings are held in the obstetrics department to investigate C-section rate, its indications, and how to prevent unnecessary C-sections. The team, consisting of well-trained doctors, labour ward staff, nutritionists, and physiotherapists, works collaboratively to encourage the patient to achieve a vaginal birth. Epidural analgesia is also offered to mothers who are worried about labour pains.
Aster Women and Children Hospital, Whitefield, has collaborated with various schools, colleges and other corporate organisations to spread awareness about the advantages of vaginal deliveries compared to C -sections.
Access to C-Section Surgeries in India
In India, a significant portion of public spending on maternal care is allocated to support poor mothers. This spending, which makes up over half of the national health budget, is directed towards programs such as the Janani Suraksha Yojana (JSY) and Janani Shishu Suraksha Karyakaram (JSSK). These programs have been in operation for over a decade and have successfully increased the demand for and use of institutional childbirth. As a result, there has been a six-fold increase in the share of caesarean births. However, it is still being determined how equitable subsidies for institutional births, including caesarean sections, are distributed among different socio-economic groups.
Policy and Programme Initiatives to improve C-Section Outcomes and reduce disparities in India
As of June 2021, 10,951 PHCs funtion 24x7. Additionally, the Government has operationalised 3001 facilities, including 690 District Hospitals, 763 Sub District Hospitals, and 1548 Community Health Centres, as First Referral Units (FRUs). The NHM aims to provide high-quality maternal and child health services with dignity and care at public health institutions. To facilitate assured admission for institutional delivery for all pregnant women, the government launched Maternal and Child Health wings. These wings are equipped with obstetric HDUs, ICUs, maternity OTs, and labour rooms to provide respectful maternity care and manage high-risk pregnancies and those requiring C-sections. They also have skill labs for training nurses and doctors to provide high-quality and skilled maternity care.
Challenges and Barriers to Implement Effective Policies in India
Developing a consistent C-section policy across the country’s various states is challenging. There might be several reasons why caesarean section delivery rates may be higher in a south Indian state than in a north Indian state.
Take, for example, Tamil Nadu and Bihar. First, Tamil Nadu has a higher prevalence of obesity, pregnancy complications, and pregnancy termination, which are all reproductive health factors associated with C-section delivery. Second, demographic factors such as late marriage and childbirth at older ages may contribute to the higher C-section delivery rates in southern states like Tamil Nadu. It has been shown that south Indian states have high levels of female literacy, lower fertility, and higher ages at marriage. Third, many economic, socio-cultural, and development-related factors, such as modernisation and high levels of urbanisation, wealthier economic backgrounds, and higher status of women, may lead to a higher probability of undergoing caesarean section delivery in Tamil Nadu. Fourth, factors related to healthcare services, such as accessibility to maternity healthcare utilisation (ANC, safe delivery, PNC) in both private and public facilities, are substantially better in Tamil Nadu compared to eastern states like Bihar. In the southern region, well-equipped healthcare facilities in public and private sectors increase the likelihood of C-section delivery.
Involving Women and Families in Decisions Regarding Childbirth
Involving women and families in decisions related to childbirth is an important aspect of providing quality maternity care. By involving women and families, healthcare providers can ensure that their care is tailored to each woman and family’s individual needs and preferences. This can help to promote patient satisfaction, improve the overall quality of care, and reduce the likelihood of negative outcomes.
To involve women and families in decision-making, healthcare providers can encourage open communication and dialogue, provide women and families with information and support, and offer a range of options and choices for childbirth. In addition, involving women and families can help empower them and promote their autonomy, enhancing their overall childbirth experience.
Addressing the underlying social and economic determinants of disparities in C-section outcomes is crucial for improving maternal health in India. The social determinants of health, such as income, education, housing, and access to affordable healthcare services, play a significant role in determining health outcomes and health inequities.
To address these disparities, it is necessary to implement policies and programmes that address the underlying social and economic determinants of health. This may include strengthening the regulatory protocols for private health facilities, increasing access to affordable and high-quality maternal healthcare services, and promoting healthy behaviours among expectant mothers.
Telangana has reduced its rate of caesarean deliveries by nearly 6% in the last year. The state has implemented several measures, including stopping incentives for C-sections, providing team-based incentives for normal deliveries, urging people not to choose an "auspicious" time for delivery, and teaching exercises to pregnant women to help with normal deliveries. Audits and awareness sessions with gynaecologists have supported these efforts. This is an example worth emulating by other states.
In conclusion, the rising trend of C-section deliveries in India is a cause for concern due to its potential negative consequences on maternal and new-born health. The main factors contributing to this trend are increased access to healthcare facilities, especially in the private sector, and a lack of awareness and education about the risks and benefits of C-section deliveries.
To address this issue, the government must implement regulatory measures to ensure that C-section deliveries are only performed when medically necessary. In addition, educational and awareness-raising campaigns should be implemented to promote the importance of natural childbirth and the potential risks of C-section deliveries. Addressing the underlying causes and promoting evidence-based solutions can reduce the prevalence of unnecessary C-section deliveries in India and improve maternal and new-born health outcomes.