Why are cesarean births in JK 'alarmingly' high?

From lack of awareness regarding benefits of natural births, to infrastructure & manpower crunch, late marriages, & ‘financial interests’, a host of reasons are responsible for the trend; disadvantageous for mother as well as her child

A major health concern is staring at women in J&K, with “too many” would-be-mothers opting for surgical births or cesarean sections. In terms of numbers three out of every four births take place surgically in J&K hospitals. The state is among top five states in terms of rate of cesarean sections. However, despite these “worrying figures” there is no urgency shown to encourage women to give birth naturally which is not only beneficial health-wise for a mother but her child as well.

While World Health Organisation (WHO) has recommended a rate of 10 percent to 15 percent for cesarean or C-section deliveries, in the last decade or so the numbers have escalated to a worrying level in the state, as has been the case in other states. And everybody from policymakers to doctors and patients are seen responsible for the trend.

In 2016, Union health ministry ordered all states, including J&K to carry out a prescription audit of private health care establishments under Clinical Establishment Act to rule out malpractice regarding what a doctor prescribes an expecting mother as a mode of giving birth. The ministry wrote that the audit “may be extended to public health care facilities too”.

However, two years hence, the audit is yet to begin. While the communication clearly hinted at an element of suspicion regarding necessity about such a large percentage of C-sections and pointed towards “malpractice”, experts in Kashmir have a different take. With the improved access to healthcare facilities and increased awareness about having a healthcare provider oversee birthing process, over 85 percent of deliveries in J&K are now institutional, according to data by National Family Health Survey – 4. A decade ago, the percentage of institutional deliveries stood at a little over 50 percent. This increase in institutional deliveries has had two impacts, doctors say. On one hand, women who choose to deliver in a healthcare facility have “misplaced” expectations.

A large number of women in Kashmir believe that delivering in a hospital means intervention of a doctor in natural birth process, gynecologists complain, and that “intervention” translates into a “surgical blade”. “If a woman has come to a hospital, she expects a pain-free birthing experience,” said Prof Shahnaz Taing, head department of gynaecology at Government Medical College Srinagar who is heading Kashmir’s only maternity hospital Lal Ded.

“The moment labour pain ensues, or even before it, the woman and her entire family push for C-section,” she said, asserting that there has been a huge increase in “cesarean section by demand”. In first time mothers, a natural birthing process takes around 15 hours from onset of labour pain to child birth, she says, and that is what “scares women off”. “They (women) are not ready to undergo this pain and demand a CS.” Although health experts hold low awareness about fallouts of C-sections and low motivation among women for going for natural birth as a major reason for a high rate of C-sections in state, there is another underlying cause that could explain the high percentage in J&K. Due to late marriages, a huge majority of women have their first pregnancies around 30 years of age. “A couple of decades back, women started families when they were in their early 20s, an age when pregnancies are expected to be less complicated,” says Prof Taing.

The late age at the time of pregnancy, comes with many complications. Prof Farhat Jabeen, who teaches Gynaecology and Obstetrics at GMC Srinagar and works at Lal Ded Hospital said when she started her career a few decades back there would be two out of 10 women with a high risk pregnancy. “Now it is reverse. We have a majority of our patients with high risk pregnancies,” she said. The complications that reduce chances of a natural birth including diabetes, hypertension, polycystic ovarian syndrome (PCOS), fibroids and more are prevalent in high numbers among women in Kashmir. However, even if a woman opts for a natural birth, J&K healthcare systems isn’t adequately equipped to ensure a safe and efficient delivery. 

A C-Section, according to medical literature, has many adverse effects on health of baby and mother. Although research is still emerging to elucidate impacts of this birthing process better, it has been established that babies born through CS have breathing difficulties due to less developed lungs. If the labour has not started on its own and a mother goes through CS planned earlier, there is a high likelihood that the baby is born before 39 weeks, also called “late pre-term”. There is a high likelihood of babies born though CS to require intensive care, part from higher risk to baby to develop asthma and other allergic disorders. Newer research is also pointing towards children being more likely to be obese if born by a surgical procedure. On the other hand, if a mother gives birth through a CS, she is less likely to have a natural birth process in future pregnancies. A CS also means greater possibility of low lying placenta in future pregnancies, a condition that can cause a lot of complications. A CS also means greater loss of blood, longer hospital stay and longer healing time. It comes with risk of infection and harder initiation to breastfeeding early on after birth due to effects of anesthesia. “A natural birthing process requires intense monitoring, one-on-one assistance of a trained birthing assistant and a fool-proof system to handle an emergency,” argued Prof Jabeen.

With the load that maternity hospitals in Kashmir are handling, all of this seems too much to expect. As per Union Ministry of Health and Family Welfare, institutional deliveries in J&K have increased from 68,800 in 2008-09 to 93,491 in 2016-17. During this period, just 18 gynecologist posts were added in already deficient maternity service in Kashmir. Moreover, over 50 percent of vacancies of gynecologists in Kashmir remain unfilled. There is a huge shortfall of nursing staff too. In most hospitals that provide maternity services, a single nurse is often entrusted the charge of over dozen women, making it impossible to have any chance of “confidence building” in women admitted for delivery. The dearth of hands makes it impossible to keep maternity services running round-the-clock in most of peripheral areas. A gynaecologist working in a rural hospital of Kashmir said that maternity cases are taken as out-patients. “We ask the woman to come to hospital when she reaches her full-term, admit her, carry out a CS between 10 am to 4 pm, when we have our only anesthetician present here and get it over with,” she said. “There is no other way as I cannot work round-the-clock, being only gynaecologist in the hospital,” she added. Doctors at Kashmir’s hospitals are also candid about the fact that there is “very little scope” for natural births. “At any given point, we have 10 women vying for attention.

What justice can we do to help them,” a senior gynaecologist at a Srinagar hospital said. Even at the largest maternity hospital of Kashmir, dearth of staff has remained unaddressed even while government increased its capacity from 500 beds to 700 beds a few years ago. In such a scenario, doctors in Kashmir feel that an “audit is uncalled for”. “We all know why we have such a high rate of CS in Kashmir, but is anyone ready to address the factors,” asked another senior gynecologist.