The Curious case of Cesarean Sections

Normal natural deliveries need to be promoted and a method of checks and balances in both Public and Private hospitals should be established
The Curious case of Cesarean Sections
Representational Pic

The mother is everything - she is our consolation in sorrow, our hope in misery, and our strength in weakness. She is the source of love, mercy, sympathy, and forgiveness. He who loses his mother loses a pure soul who blesses and guards him constantly: Khalil Jibran

The dominant discourse of motherhood has remained stable through several centuries; motherhood is viewed as the main purpose in life of every woman and the most illustrious of states. Through much of recorded history, and guided by patriarchal forms of thought, law, and discourse, motherhood has been presented as women’s ultimate purpose and main mission in life, to be a holy mission and the highest form of service to humanity.

A well-known summary of the ideology of motherhood is the “belief that all women need to be mothers, all mothers need their children and all children need their mothers” (Oakley, 1986: p. 67).

Cesarean section has been part of human culture since ancient times and there are tales in both Western and non-Western cultures of this procedure resulting in live mothers and offspring. According to Greek mythology Apollo removed Asclepius, founder of the famous cult of religious medicine, from his mother’s abdomen. Numerous references to cesarean section appear in ancient Hindu, Egyptian, Grecian, Roman, and other European folklore. Ancient Chinese etchings depict the procedure on apparently living women. The Mischnagoth and Talmud prohibited primogeniture when twins were born by cesarean section and waived the purification rituals for women delivered by surgery.

The first documented cesarean section in medical history on a living woman was performed in 1610; she died 25 days after the surgery. Abdominal delivery was subsequently tried in many ways and under many conditions, but it almost invariably resulted in the death of the mother from sepsis (infection) or hemorrhage (bleeding).

1794: Elizabeth Bennett delivers a daughter by cesarean section, becoming the first woman in the United States to give birth this way and survive. Her husband, Jesse, is the physician who performs the operation

In modern obstetrical care, cesarean section usually is performed when the life of either the mother or the child would be endangered by attempting normal delivery. The medical decision is based on physical examination, special tests, and patient history. The examination includes consideration of any diseases the mother may have had in the past and disorders that may have arisen because of Pregnancy Special tests that might be performed include fetal scalp blood analysis and fetal heart rate monitoring. Common indications for cesarean section include obstructed labour, failure of labour to progress, placenta praevia (development of the placenta in an abnormally low position near the cervix), fetal distress, gestational diabetes mellitus, and improper positioning of the fetus for delivery. In addition, cesarean section is often used if the birth canal is too small for normal delivery. Sometimes when a woman has had a child by cesarean section, any children born after the first cesarean section are also delivered by that method, but vaginal delivery is often possible.

Normal Delivery vs Cesarean Section

In terms of the global scenario, the previous studies show that in both the developed and developing countries, there is a large increment in the rate of C-section as a country shifts from lower to higher Human Development Index (HDI). However, it can be seen that the rates are consistently rising even within the HDI categories. Currently, no internationally accepted classification system for the C-section is available to allow meaningful and relevant comparisons of C-section rates across different facilities, regions or cities. Among the pre-existing systems used to classify C-sections, in recent years, the 10-group classification (Robson classification) has been widely used in many countries. In the Indian context, 17% of live births, as per the National Family Health Survey (NFHS-4), in the 5 years before the survey were C-section deliveries. Moreover, 45% of the C-section deliveries were reportedly planned after the onset of labour pains (NFHS-4). The prevalence of the C-section in India was 8.5% in NFHS-3 while data in NFHS-4 show that it has increased to 17.2%. Thus, almost 9% has increased over 10 years. This study thus delves deep into understanding the change in the rate of the C-section deliveries and identifying the various factors affecting the increment in the C-section rates.

NFHS -5 and alarming trends

An increasing number of women in India have been undergoing a cesarean section (C-section) to deliver babies compared to five years ago, data from the National Family Health Survey 5 (NFHS) on delivery care has revealed.

C-section births in India increased 4.3 percentage points over five years: To 21.5 per cent (NFHS-5) from 17.2 per cent (NFHS-4, 2015-16).

Nearly half the total C-section births (49.3 per cent) took place at private health facilities in urban areas; in rural areas the figure was 46 per cent. The total number of births increased 6.5 percentage points in private health facilities — up from 40.9 per cent (NFHS-4) to 47.4 per cent (NFHS-5).

Curious case of J&K and increased cesarean trends

The World Health Organisation threshold of C-sections ideally between 15 to 20 %, stands breached and surpassed by a huge margin. Jammu and Kashmir, as per the recent data, is reporting an alarming rate of C-sections at nearly 42 % 2nd in the country after telangana.( NFHS -5)

If we go through district wise trends in Jammu and Kashmir, Pulwama tops with c section rate of 80% , Srinagar 73% , Budgam 62% , Baramulla , Anantnag and Kulgam at 57 -56 %. In Jammu Division Jammu (50.9), Samba ( 44.6) , Kathua (36.2) , Rajouri 28.1.

Overall the districts with lowest rate are Reasi ( 2.1) , Ramban ( 11.4) , Kishtwar ( 19.5) Udhampur (20.9) and Doda ( 24 %) all Jammu Districs which are mostly hard to reach and mountainous.

Debate and possible solutions

What’s wrong in Kashmir division and capital districts of Jammu and what are possible solutions, we contemplated at the National Health Mission Headquarters. Mission Director NHM J&K called all concerned and deliberations began. All the stakeholders including major HoDs of Obs and Gynae of Associated Hospitals, Gynecologists from Field Hospitals, Public Health Experts from Partner Organizations like WHO, UNICEF, JSI, NIPI etc., started to strategize; yes the rate is alarmingly high, normal natural deliveries need to be promoted and a method of checks and balances in both Public and Private hospitals should be established.

Solutions and strategy

1) Catching them Young: Early sensitization and behavioral change communication of all ANC check ups of pregnant females to promote natural birth deliveries ( ASHAs, ANMs, Mid wives, Nurses, doctors at all levels, help from social organizations, Inter-sectoral convergence with other departments like Education, Social Welfare, NGOs, PRIs).

2) Robust Communication Strategy: IEC and involvement of print, electronic and especially social media in promoting normal deliveries and explaining its benefits to masses will be a game changer.

3) Fixing accountability at all levels: Who are doing these cesareans in both Public and Private and what are the indications need to be ascertained hence the AUDIT.

4) C-Section Audit: Daily, weekly and monthly formats have been introduced in all maternity hospitals across UT of Jammu and Kashmir through which we will access the indications of conducting C sections , these formats have to be filled by all operating doctors at tertiary hospitals, District hospitals, Sub district hospitals and private hospitals every day before conducting C – section explaining the reasons and indications for the same also giving reasons why Normal Delivery could not be performed in that case.

These formats will be examined at Distract level send to State team and will finally go to Maternal Health Division MOHFW Govt of India for further scrutiny.

1st MCH Conclave J&K

First of its kind in the history of Jammu and Kashmir the Health Department is organising MCH Conclave where all Maternal and Child health issues, indicators will be discussed. Two day conclave will be held around 6th and 7th of June and all leading experts across India and abroad will be participating to chalk out a road map for further decreasing IMR and MMR in J&K.

Dr Qazi Haroon is State Project Manager NHM J&K, Programme Incharge Maternal Health for NHM J&K.

Disclaimer: The views and opinions expressed in this article are the personal opinions of the author. The facts, analysis, assumptions and perspective appearing in the article do not reflect the views of GK.

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