Giving birth in this part of the earth- India and the rise of cesarean surgery

By Zoe Quinn

If you are living in urban India, you have probably noticed something. If you haven’t- talk to women in your society, or friends and family around your age, and ask “how was your birth,” you will quickly learn that a cesarean surgery (a c-section) is now very common. In fact, some places in India, cesarean surgeries are more common than a vaginal birth and purely natural births (no medical interventions)? On the verge of extinction.

We all know that a cesarean surgery can be a life-saving procedure and sometimes it the safest way to bring a baby “earthside.” But, if cesarean surgeries are performed only truly needed, we shouldn’t see rates go higher than 10 to 15%. Man practitioners with experience in natural birth of surgical rates as low as 1%. The World Health Organisation states that once cesarean surgery rates go higher than 10% at the national level, you no longer see any dips in maternal and infant death. And after 15%, the national rates of death related to childbirth begins to rise.(1)

Note, however, if you look at the numbers in a good midwifery practice, you will commonly see cesarean rates under 10% and some even under 5%. BirthVillage in Cochin, who serves healthy, low-risk women, reports that 97.6% of births are normal. Similarly, The Sanctum in Hyderabad has a 93.2% normal birth rate. These centres have a high normal birth rate, despite also caring for HIGHER-RISK mothers with more complex needs, including VBAC, gestational diabetes, High BP, twins, and breech. The key here is that these birth centres are run by MIDWIVES who are educated about in lifelong physical and psychological health benefits of natural birth to both mothers and babies, they are committed to providing optimal health to mothers and babies, and they also believe in a woman’s capacity to birth. They also take many efforts to prepare their clients psychologically for a natural birth, the key to their success is that families are confident, informed, and strong before they go into labour!

Despite the recommended cap on cesareans, the rates of surgical births are uncontrollably rising in India, and worldwide. According to the latest National Family Health Survey studying families from 2015-2016, on average, almost 45% of urban Indian woman going to a private hospital will have a cesarean surgery. (2) Public hospitals have lower surgical birth rates at 20%. (3) However, both of these figures are well above the recommended level of cesarean surgeries.

Keep in mind that these stats reflect an average of all of India. Your state, district, particular hospital or even chosen care provider may have very different statistics. I have personally spoken to obstetricians in the Pune area who have cesarean rates of 80%, 70%, and 25%. All of these obstetricians serve a similar middle to the high-income urban population within 5 square kilometers of one another. Many pregnant women report not personally knowing any peer that has had a normal birth.

So what’s going on?

There are many reasons contributing to the rise of surgical birth in India. The medical model of care, fear, awareness, normalisation, convenience, and cost are probably the most significant reasons. Note that I haven’t listed because ‘women ask for them.’

MEDICAL MODEL (and absence of midwives)

Maternity care falls into the category of the medical model of care or midwifery model of care. India follows the medical model of care. The medical model focuses on the detection, prevention, diagnosis and treatment of any complication during pregnancy, childbirth and after that. There is a lot of routine, standardised care, (meaning test and procedures done to all women, regardless of actual need) and highly trained surgeons oversee the birth (obstetricians). There is a tendency to intervene during childbirth, often unnecessarily.

The midwifery model of care, on the other hand, treats pregnancy and birth as a very important life event for women but a normal physiological process that usually works well with a healthy, uninhibited mother and therefore aims to minimise interventions and preserve the integrity of the MotherBaby’s birth experience. Midwives are fully equipped clinicians who can manage many conditions on their own and even within the home, they also know when a situation arises, and they need to hand care over to a surgical unit. Natural birth is the norm in countries that follow the midwifery model of care.

In many countries, midwives are the primary care providers for most women and most of these women will never meet an obstetrician during their pregnancy and birth. The midwifery model of care is known for better outcomes, fewer interventions (including low cesarean rates), and higher satisfaction rates. However, India follows the medical model of care, and the normality of normal birth is corroding.

FEAR

Giving birth for an educated, well nourished, healthy women living in a clean and safe environment is the safest it has ever been in history Nutrition, sanitation, skilled support practitioners, and in rare cases access to surgical facilities, are the keys to healthy outcomes. Ironically, though many women have all these things, they have never been more afraid of birth and doctors are doing surgeries on healthy women. Fear of birth drives many unnecessary interventions in an attempt to feel more in control of birth, including birthing in a hospital. Fear in a woman can significantly alter her labour process, making it more difficult for her to necessarily soften and open up. Also, mainstream media usually depicts childbirth in a dramatic or horrific way conditioning our expectations of birth. It’s not easy to give birth with confidence when we have been conditioned to fear it. It’s also not easy for care provider’s to stand by and not intervene when they don’t trust birth.

AWARENESS

Both women and health care professionals have yet to understand (or rather, have forgotten) the significance birth has in a woman, her baby and her family’s life. The value of birth in our lives has been degraded, is feared and not looked upon with the deserved reverence or awe. Additionally, many mothers remain unaware of the risks of cesarean, including the lifelong health disadvantages of a cesarean birth. Many women think it’s a standard procedure that is safer than a normal vaginal birth. It is not. Women are not being informed by health care professionals, that compared to a normal birth, birth via cesarean for both mother and baby carry many more risks, including death. Not to mention, it disrupts a complex hormonal process that can significantly impact our path through motherhood and our baby’s emergence into being and lifelong health.

Check out the latter section to learn more about the risks and benefits of cesareans.

NORMALISATION

Cesarean surgery is common among women getting care from the private sector; it has become normal. When I tell people I had a natural birth, many are shocked! I have asked mothers how their birth was and I have heard responses like, “Oh, it was normal!” leading me to assume she had a vaginal birth. But soon I learned they had a surgical delivery!

Cesareans are common and accepted, and thus, we are no longer aware of the harm that they cause. Many people feel a cesarean is not a big deal when that couldn’t be farther from the truth. Yes, cesareans are significantly safer than they were 50 years ago. But nonetheless, a cesarean is surgery and a major one. While many women can have positive birth experiences with a cesarean and sometimes it is the safest way to give birth, the majority of women do not require to have major abdominal surgery to give birth to a baby safely.

CONVENIENCE/PROFIT

A cesarean surgery can have a baby out, and mother stitched back up in 20 minutes. That is a lot quicker and more predictable than a normal birth which can take hours or even days for a mother to birth her baby. However, many forget to factor in that the mother must stay in the hospital a few days longer and it takes much more time to recover – this makes more money for the hospital.

It is easier and faster for a doctor to cut the baby out, rather than wait. The doctor can attend to more women per day if he or she doesn’t have to wait for labour. For some doctors, there may be a monetary incentive to do a cesarean surgery. But for many doctors, they are trapped in a system that buries them in “patient” load.

However, it’s my belief that most doctors are trying to do good. But waiting through a labour means more time that they are held responsible for you and your baby, and that pressure is not so easy to bear. Therefore they can be unknowingly inclined to push for a cesarean so they can get the birth “over and done with” and feel relaxed that the baby is out. This pressure combined with their training (which focuses on the complications of birth) make it hard to wait it out as a vigilant but low-profile observer.

Some women may opt for elective cesarean surgeries out of convenience as well. With a cesarean, everything is predictable, and she can know what day the baby will be born. Sometimes the desire for a cesarean birth comes from wanting the baby to be born on an auspicious day. However, It’s my feeling though that most women are not pushing for cesarean surgeries. At least in the US, not more than 2% of women request caesarean for non-medical reasons (no figure available for India). (4)

Regardless, it is my belief that the vast majority of women would opt for a normal, spontaneous birth if they knew the full scope of risks and benefits of each type of birth.

Are cesarean surgeries really that bad?

Even though some doctors proudly proclaim that they can have women back home from a cesarean surgery within 24 hours, that is not common, and the story doesn’t end just because a woman has been discharged. Statistically, a cesarean birth still carries more consequences and is riskier than a normal vaginal birth. Here’s why:

Short term risks of cesarean surgery: (5)

  • Blood clots
  • Stroke
  • Infection
  • Pain after birth
  • Separation from your baby
  • Psychological trauma
  • Longer hospital stay
  • Emergency hysterectomy
  • Death (somewhere around a 69% more likely than a vaginal birth) (6)

Long term risks of cesarean surgery: (7)

  • Pelvic pain
  • Bowel obstruction
  • Infertility
  • Complications of future pregnancy problems including ectopic pregnancy (the baby developing in the wrong place outside the uterus), placenta previa (placenta forming over the cervix) and uterine rupture
  • Subsequent cesarean surgery in future pregnancies

Compared to a vaginal birth, your baby is at an increased risk of: (8)

  • Injury during birth (usually from being nicked by the knife)
  • Respiratory (breathing) problems
  • Difficulty establishing breastfeeding
  • Being admitted to the Neonatal Intensive Care Unit
  • Being separated from his/her mama
  • Long-term health issues later in life like asthma, allergies, diabetes and gut disorders like Celiac disease or Crohn’s disease. (9)
  • Loss of important bacteria gained to “seed” his/her’s gut to form a healthy immune system (which would otherwise be retrieved through the vaginal canal). (10)

Note, most of these risks are quite small. They are however greater than if the baby is born naturally. In general, a natural birth is also much gentler for the mother and baby, usually more satisfying, and physiologically prepares the dyad for an ongoing successful relationship. But, normal birth is not without risks because birth is a major phenomenon of life and like every life activity, there are some risks, even things that are good for us.

If women learn about all the risks that a cesarean surgery entails and compare that to the risks/benefits of normal birth (which I didn’t touch on), the vast majority of women will want to do what they can to achieve a normal birth.

So you want to avoid an “unnecesarean”?

By Ruth Malik

Take a look at the following misleading reasons women are falsely given to get them to consent to unnecessary surgery. A cesarean surgery done based on any one of these conditions alone is probably done so unnecessarily. While emergencies, often unpreventable emergencies that unquestionably require a cesarean delivery do occur, they are rare. With planning, communication, and a health care professional who is on the same page, a vaginal delivery is totally possible for a healthy woman.

You’ve gone past your due date (i.e. overdue)

The duration of most pregnancies is 38 to 42 weeks; 42 weeks is considered post dates and it may be a good idea to induce labour, not necessarily to have a C-section. There are many natural ways to induce labour.  In India, most doctors and hospitals do not follow the standard of 42 weeks, but rather advise surgery or induce labour by week 39 and as early as 37 weeks. Overdue is one of the most common reasons for unnecessary C-sections.The general rationale for a baby to be born at 39 weeks is that the infant death rate is lowest by this week and after 40 weeks, the likelihood of a stillborn ( a baby dying in the womb) steadily increases. However, the risk of a stillborn at 42 weeks is still quite small (around 1 in 1,000) which is not that different from the risks of a spontaneous birth at 39 or 40 weeks. (11). If mothers count 6 to 8 kicks a day in the last month of pregnancy they are safe and can go to the doctor if the kick count reduces.

The umbilical cord is wrapped around the baby’s neck!

 

Cord around the neck is also one of the most common ‘unnecesareans’; C-sections due to a cord wrapped around a baby’s neck are virtually unheard of outside of India, since instances in which the cord tightens to the point of threatening the baby’s life are rare. About one in three babies will be born with a cord around the neck in countries like the US that don’t cut babies out for this reason. (

The mother is too old/big/small

No matter how old, petite or obese a woman is, or how narrow her vaginal passage, a vaginal birth is almost always possible. Also, even if a woman’s pelvis appears small, it may still open enough to allow the baby to pass through, particularly when she’s squatting or in a position other than laying on her back. The pubic symphysis is the midline cartridge joint uniting the left and right pubic bones, it softens and opens during birth. The baby’s skull is also not fully fused and can mould, throughout labour to accommodate tight spaces.  No one knows how much a pelvis will open and how well the baby will squeeze through until labour. True cases of a baby not fitting through a mother’s pelvis are either because of rare pelvic abnormalities (like if the mother suffered severe malnutrition during childhood) or unusually large babies from actually diabetic mothers, but mind you, many of mother’s have given birth to 4.5kg babies, naturally!.

The mother has diabetes / gestational diabetes

Diabetes or Gestational diabetes can have implications for the baby’s health growth in utero, but these usually conditions have no effect on the birth. This reason alone shouldn’t necessitate a surgery. Avoiding sugar, packaged foods, drinks, fruit and carbohydrates can bring sugars down.

The mother has fibroids

Many women get uterine fibroids – i.e. non-cancerous tissue growths during pregnancy, and they are typically a non-issue. Fibroids make spontaneous miscarriage a bit more common. But for a woman who has reached full term, fibroids alone usually don’t warrant a cesarean. They may cause a problem if the fibroid is large and blocking the cervix. Fibroids also increase the incidence of breech babies (bum down and head up). (13)

The mother’s heart rate or blood pressure is high

While an increase in heart rate and elevated BP might be a sign of a more serious condition like pre-eclampsia, it is also a natural reaction to the stress of labour and there are many ways to bring it within normal range. Unless further signs of a more serious condition develop, high BP alone is not reasons for surgery. Mothers lying flat on their back will experience high BP as the vena cava vessel is pressed upon.

The mother has been labouring for a long time

Some doctors and hospitals impose 12-hour time limits of active labour, which is unnecessary. The 12-hour time limit is based on the outdated “Friedman’s Curve.” Imposing this time limit arbitrarily and unnecessarily leads to increased diagnosis of “failure to progress” The problem is actually  “failure to wait.” As long as the mother is coping and there is no sign of distress, a mother can continue to labour for as long as she needs.

The mother is delivering multiple babies

Giving birth to twins or multiples is not inherently a reason for a cesarean delivery. However, it does require an experienced and confident doctor to deliver multiples vaginally.

The amniotic fluid is low/high

More technically known as oligohydramnios and polyhydramnios, these two conditions may be an indication to induce labour, but not necessarily to have a C-section. If low/high amniotic fluid alone is the only abnormal condition, it’s usually reasonable to go for a normal birth.

The water broke!

This is a normal part of birth that signifies the onset of labour within the next 72 hours typically. If there is no fever, blood or meconium, there is no need to remove the baby immediately via a cesarean surgery. Many of the times hospitals have strict time limits (24 hours or less) on the birth that are unrealistic and rush women into have highly interventionist births and cesareans because of fear of infection. This 24-hour limit policy was outdated research (from 1950’s and 60’s) when care was very different, and antibiotics were not used. Also, vaginal exams are the main culprit regarding the mother getting an infection. It is acceptable and evidence-based to wait 24-72 hours before intervening in the mother shows no sign of infection. (14)

You had a previous cesarean

Vaginal birth after cesarean (VBAC) is still very UNCOMMON in India. Many hospitals have VBAC bans, or individual doctors won’t do them. Even those who do tell women they can try for a VBAC may have very low success rates (like a “VBAC” doctor I met in Pune who has a success rate of only 20%, other practitioners have an 85% success rate).

There was once a saying that, “Once a cesarean, always a cesarean.” This thinking was the result of some catastrophic instances of uterine rupture (the scar from the previous cesarean splitting during labour). However, researchers found that most of these cases were due to the flagrant use of a labour stimulating drug. This drug is now not usually used to speed up labour. Induction medications should not be used for VBAC mothers.   In light of this understanding, authoritative groups from around the world – like the American College of Obstetrics and Gynecology (ACOG) or the Royal College of Midwives (RCM) and even the National Institute of Health and Excellence (NICE) – support women to have VBACs! In fact, in the UK, after a mother has had her first cesarean, they now immediately provide her with pamphlets and information encouraging her to have a VBAC with her next pregnancy. (15)

If your care provider does not support a VBAC birth, find one who does!

The baby was conceived via IVF

The means of conception have nothing to do with the method of delivery. They are entirely different biological processes with nine months in between.

The baby is in OP (posterior) position

OP or the occiput posterior position means the baby is in a head-down position, but the baby’s back lies against the mother’s back. Face-back is the ideal birthing position for a baby, but birthing a baby face-up is also possible if the care provider is experienced. Many, however, are not. Mothers with an OP baby need more encouragement, movement, possibly pain relieving measures and usually time- not necessarily surgery.

The baby is in breech position

Similarly, a baby in a breech position – that is, a feet-down position – is not inherently a reason for a C-section. However, it does require an experienced and confident doctor to vaginally deliver babies in a breech position.

There are also many techniques to turn a breech-position baby to a head-down position prior to delivery, though they require experience to attempt. Very few doctors now have the experience and training to deliver or turn breech babies, which is why they may recommend a cesarean delivery; certified professional midwives usually do have such training.

The baby’s head is not engaged

Also called a high, floating head, this means the baby’s head has not ‘dipped’ or entered the area within the mother’s pelvis.

This is common, particularly for second pregnancies and beyond, when babies’ heads typically engage sometime during labour, rather than before (as is typical for first pregnancies). Time and patience are all that is needed for the head to engage.

The baby is too large

A large baby, or, macrosomia, is a very rare condition associated with gestational diabetes. There is no medical reason that necessitates a cesarean surgery. Many “large babies” are diagnosed by end of pregnancy scans which are notoriously unreliable – advice for a cesarean solely based on one of these scans is suspect.

Want to know more?

If you would prefer to have a vaginal birth, it’s important to discuss with your doctor and hospital your birthing preferences early and often. Ask specifically about their C-section statistics and how he/she supports natural birth in order to learn about their birthing practices. Ask about what hospital policies are in place that supports a woman for natural birth.  If you don’t feel confident – switch! Birth in a birth centre run by midwives with 98% natural birth or find at least three women who have had the birth that you want then you most likely have found the right doctor. The care provider you have chosen can significantly alter your birth process, so choose wisely! Also, consider taking independent childbirth classes that aim to equip you with good information and confidence.

One way to avoid an “unnecesarean” is to choose a care provider who has a low cesarean rate. However, it can be hard to obtain this information, and many women are shy to ask. But knowing your care provider’s cesarean rate is key to helping you make informed choices. Ruth Malik and Subarna Ghosh of Birth India in collaboration with Chage.org, have created a petition that requires private hospitals to release their c-section rates, help us by…

signing the petition!

 [Please note: the intention of this article is in no way meant to shame women who choose or who have had cesarean surgeries. Birth India wishes to honour and respect every woman and her choices. Cesarean births are the right birth for some women and cesareans can be very positive as well. However, rising unnecessary cesarean surgery rates are a public health concern. It is our aim to give women good information to make fully informed choices about their care. XOXOX.]

 

REFERENCES:
    1. Who Statement on Cesarean Section Rates. (2015) http://apps.who.int/iris/bitstream/10665/161442/1/WHO_RHR_15.02_eng.pdf
    2. National Family Health Survey Fact Sheets: India (International Institute for Population Studies). http://rchiips.org/NFHS/pdf/NFHS4/India.pdf
    3. National Family Health Survey Fact Sheets: India (International Institute for Population Studies). http://rchiips.org/NFHS/pdf/NFHS4/India.pdf
    4. Maternal Request for Cesarean Delivery: Myth or Reality? (2013) http://www.ourbodiesourselves.org/health-info/maternal-request-for-cesarean-delivery-myth-or-reality/
    5. Lothian J., DeVries C. Giving Birth With Confidence. Meadowbrook Press New York. 2017
    6. MacDroman MF, et. al. Neonatal mortality for primary cesarean and vaginal births to low-risk women: application of an “intention-to-treat” model. PubMed. 2008. https://www.ncbi.nlm.nih.gov/pubmed/18307481
    7. Lothian J., DeVries C. Giving Birth With Confidence. Meadowbrook Press New York. 2017
    8. Lothian J., DeVries C. Giving Birth With Confidence. Meadowbrook Press New York. 2017
    9. Harman, T., Wakeford, A. MicrcoBirth. 2014. Film
    10. Harman, T., Wakeford, A. MicrcoBirth. 2014. Film
    11. Dekker, R. Evidence on Inducing Labor and Going past your Due Date. April 15, 2015. https://evidencebasedbirth.com/evidence-on-inducing-labor-for-going-past-your-due-date
    12. Hutchon, D. Management of Nuchal Cord at Birth. Journal of Midwifery and Reproductive Health. October, 2013. http://jmrh.mums.ac.ir/article_1249.html
    13. Guo, X. C., & Segars, J. H. (2012). The Impact and Management of Fibroids for Fertility: an evidence-based approach. Obstetrics and Gynecology Clinics of North America, 39(4), 521–533. http://doi.org/10.1016/j.ogc.2012.09.005
    14. Dekker R. What is the Evidence for Inducing Labor if your Waters Break at Term? Novemeber 10, 2014 https://evidencebasedbirth.com/evidence-inducing-labor-water-breaks-term/
    15. Explanatory Letter to women who have had a cesarean section. York Teaching Hospital. April 2013. https://www.nice.org.uk/sharedlearning/explanatory-letter-to-women-who-have-had-caesarean-section
Zoe Quinn is a volunteer for Birth India. She is American but has lived outside of Pune, India since the beginning of 2013. She is married to a Maharashtran and they enjoy one wild son together. After a fantastic homebirth in 2014, she has been on her path to become a midwife and advocates for safe and joyful physiologic birth.
Ruth Malik is the Founder/Coordinator of Birth India. After two avoidable and unnecessary caesarean surgeries, Ruth’s traumatic birth experiences motivated her to start Birth India.

A Postgraduate in International Health, a trained doula and hypnobirthing practitioner, with 14 years of experience supporting women to make informed choices in pregnancy and childbirth. Mum to 14-year-old Jai and 10-year-old Sophia. An Australian national, Ruth has lived in India since 1996 both in New Delhi, and Mumbai. Ruth Malik is currently the education manager at Medela India.

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