Balancing the knife: India debates the pros and cons of pushing caesarean sections
BMJ 2022; 378 doi: https://doi.org/10.1136/bmj.o1915 (Published 03 August 2022) Cite this as: BMJ 2022;378:o1915
Lakshmi was due to deliver her baby in a week, so her in-laws called an astrologer to find the perfect “muhurat”—an auspicious time and day—to have the baby delivered through caesarean section.
Muhurat deliveries have become a trend in India, with families believing that a task performed at a certain time on a given day gives a positive result. This belief, mixed with other reasons such as fear of labour and desire for a painless delivery, is pushing more Indian women to opt for caesarean sections to deliver their babies.
The rate of caesarean deliveries in India more than doubled from 8% in 2005 to 17% in 2016. According to the most recent (2019-21) data from the National Family Health Survey conducted by the Ministry of Health and Family Welfare, the number of caesareans performed in India rose from 17.2% in the previous (2017-19) survey to 21.5%. (For comparison, in the US 31.8% of live births were caesareans in 2020,1 while in the UK one in four women giving birth has a caesarean.2)
With one of the highest rates of infant mortality in the world—27 deaths out of every 1000 live births in 2021, according to data from the Organisation for Economic Co-operation and Development—the rise in caesareans should be a good thing. But measures seeking to make them more available to women in need are clashing with moves to cap the trend in “unnecessary” procedures, amid a complicated debate about what is medically appropriate and who can decide.
Increased age, increased need
Meena Kumaraswamy, 35, was rushed to a hospital in Chennai after she began having contractions during India’s first covid-19 lockdown in 2020. As Kumaraswamy wanted to have a vaginal birth, the doctor suggested a drug which would speed up labour. After taking the drug her pains intensified, but even after a couple of hours there was no significant dilation and the baby’s heartbeat was slowing down.
Kumaraswamy had an emergency caesarean and delivered a healthy baby. “I very much wanted to have a vaginal birth, but because of the circumstances doctors had to deliver my baby by caesarean. I am grateful to have a healthy baby,” says Kumaraswamy, holding her two year old son.
With women like Kumaraswamy giving birth later in life, in some ways the increase in caesareans is not surprising, says Kavita Naragoni, obstetrician, laparoscopic, and robotic surgeon at Continental Hospitals in Hyderabad. “25 to 30 years back, the age of the mother when she had her first child was around 20, now women are delivering babies at older ages of 30 plus,” she says. “Naturally, the percentage of caesareans will increase with the age of the mother and the increased weight of the baby.” Gestational hypertension and diabetes, increased maternal age, placental abnormalities, and less amniotic fluid in the womb can all complicate delivery, and any delay in deciding on an emergency caesarean may prove hazardous for the baby and mother, says Naragoni.
The pattern of caesareans is not uniform across the country. According to the National Family Health Survey, Telangana state in the south has the highest rates—60.7% of all deliveries in the state were caesareans,3 with muhurat and fear of labour cited as common reasons.4 The north east states of Meghalaya, Mizoram, and Nagaland recorded the lowest numbers of caesareans (8.2%, 10.8%, and 5.2% respectively,5 though the north east has low infant mortality compared with other states6).
The National Family Health Survey revealed that 47.5% of babies born in India were born in private hospitals through caesarean. Some states are showing triple the number of caesareans in private hospitals compared with public hospitals—in Tripura 69.3% of all births in private hospitals were caesareans, in Andhra it was 63%, and Chhattisgarh 57%, this compared with 22.7%, 26.6%, and 8.9%, respectively, in government facilities.
But the life saving nature of caesareans is being overshadowed by high rates and a spotlight on unnecessary procedures done for personal preference or profit.
Financial incentives
In 2017, a bill, the Protection of Women from Unnecessary Caesarean Section Deliveries,7 was introduced in the Indian parliament. It stated that unnecessary caesareans were being carried out for financial gain as charges are higher for caesareans compared with vaginal deliveries.
This is in part because of increased insurance coverage in recent years, according to Indu Bhushan, who was the chief executive of Ayushman Bharat, an Indian government agency providing national healthcare coverage to people with lower incomes. In an interview with newspaper The Print8 he explained how the Ayushman Bharat Pradhan Mantri Jan Arogya Yojana scheme—available since September 2018—offers qualified families 500 000 rupees (£5239) of annual health coverage, giving access to private healthcare facilities that may be closer and are often better equipped than government hospitals. Since an insured person is guaranteed to pay, private hospitals are happy to perform caesareans for non-medical reasons.
Over the past few years, state governments have taken action. In December 2021, the health minister of southern Tamil Nadu state asked all hospitals to reduce the number of caesareans to 20%.
Three hospitals in Nirmal district in Telangana were penalised by being closed down for breaching the number of allowed caesareans in April,9 a decision opposed by local doctors. “Such allegations are baseless and biased, and we demand the immediate reopening of the closed hospitals,” Sampath Kumar, president of the Telangana chapter of the Indian Medical Association, told The Hans India newspaper.10
July 2022 saw a meeting in Karimnagar district in Telangana between district officials, local priests, and astrologers, who agreed to support the state government in reducing the number of caesareans performed.11
In north Telangana, where over 90% of births are by caesarean, district officials announced that every hospital would be charged with actively reducing the number of procedures. A source in the Nirmal district government told The Hindu that it was looking at scrapping an incentive that awarded 11 000 rupees for caesareans to healthcare workers and replacing it with one of 3000 rupees for vaginal delivery.
Who decides?
The question is who takes responsibility when it comes to caesareans?
“Nobody can force a doctor,” says Rani Nandakumar, a gynaecologist working in Apollo hospital at Chennai. “Doctors carry out a caesarean based on the condition of the mother and the fetus and all protocols are followed according to medical ethics. Practices like paying incentives for caesarean or vaginal births must be banned and punished wherever it happens.”
Conversely, this places a lot of responsibility on that doctor’s shoulders; Naragoni points out that India doesn’t have a midwifery system like other countries. (Accredited social healthcare activist workers (ASHA)—India’s unique group of all-female community health workers12—have been offered incentives by the government to help convince pregnant women, particularly those in rural areas, to seek medical help for difficult births, but once the woman is admitted into the hospital, she is in the hands of a doctor.)
When deliveries have gone wrong, there have been instances of doctors being attacked by mobs, verbally and physically abused, and property damaged at hospitals. In March, a senior gynaecologist at a private hospital in Rajasthan state died by suicide after police charged her with murder after a patient died from postpartum haemorrhage during childbirth.13 Her death sparked a strike and rallies attended by private and public sector doctors in the state. “When such incidents happen, do we get exempted from medicolegal cases?” asks Naragoni.
Nandakumar says caesareans are vital, life saving procedures but have become a “double edged sword.”
“Nowadays doctors fear the patient, litigation, and physical attacks from family members and the public if something goes wrong. Doctors should be free to perform a caesarean section where such circumstances arise.”
Footnotes
Commissioned, not externally peer reviewed.
Competing interests: I have read and understood BMJ policy on declaration of interests and have no relevant interests to declare.