In China like many parts of the world, women are having more Cesarean sections than medically necessary. C-section is the No. 1 surgery undergone by women and the most common operation performed. It carries serious risks.

By Jisha Krishnan

“Unprecedented and unjustified” – that’s how an insightful study published in The Lancet last year referred to the increase of caesarean sections (C-sections) across the globe.

The number of births by C-section was about 16 million (12.1 per cent of all births) in 2000. In 2015, it was 29.7 million (21.1 per cent of all births).

Worldwide, more than one in five babies are delivered by C-section. While the numbers vary across geographies, at 6.1 per cent, South Asia has seen the fastest increase in C-section rates in the 15-year period, finds The Lancet report.

Cause for concern

A C-section – surgical procedure used to deliver a baby through incisions in the abdomen and uterus – can be a life-saving intervention. Experts concur that it is an essential part

of comprehensive emergency obstetric care, preventing maternal and perinatal mortality and morbidity when medically justified.

However, medically unjustified C-sections (performed due to fear of labour, or the convenience of physicians, or to avoid the risk of litigation, or the lure of financial incentives for hospitals) pose risks for both mothers and babies.

From increasing the likelihood of life-threatening complications in women during childbirth, such as bleeding, uterine rupture, hysterectomy and cardiac arrest, to raising the chance of obesity, autoimmune diseases, and respiratory problems in children, the perils are well-documented.

Asia angle

The World Health Organization (WHO) recommends the ‘ideal rate’ for C-sections to be between 10 and 15 per cent. In Bangladesh, it is 30.7 per cent and 30.5 per cent in Sri Lanka, says The Lancet report. India stands at 18 per cent; Pakistan at 15.9 per cent.

High prevalence of C-sections in South Asia is a worrying trend, particularly because of the gloomy maternal and child health scenarios in the region. On the one hand, women from poor socio-economic backgrounds continue to die during childbirth due to lack of access to basic healthcare facilities, while their urban counterparts in private hospitals are subjected to risky, often unnecessary C-section deliveries.

According to a recent report by Save the Children, 77 per cent of C-sections in Bangladesh last year were medically unnecessary. On the other hand, 15 women died daily due to pregnancy-related complications in the country. Can judicious and equitable use of C-sections be the answer?

The China way

China, along with Brazil, accounts for 50 per cent of the 6.4 million unnecessary C-sections across the globe. Over the last couple of years, China has implemented a multi-pronged approach to bring down the numbers. From compulsory natural birth and breastfeeding classes to retraining for physicians to strengthen obstetrics skills and more midwifery training institutes, the efforts are bearing fruit.

However, healthcare experts are divided over the justification for punitive action against those who fail to comply with the State’s guidelines. In China, hospitals are held accountable for their C-section rates; state subsidies are linked with C-section numbers; fines are imposed and hospital licences revoked in case of non-compliance.

Critics contend that the China model is so focused on keeping the numbers down that it runs the risk of denying the life-saving procedure to women who medically need it.

Moreover, it takes choice in the childbirth process away from parents. In a disturbing case last year, a Chinese woman in labour jumped out of a hospital window to her death after she was refused a C-section.

Finding middle ground

C-section rates “higher than 10 per cent were not associated with reductions in maternal and newborn mortality rates,” said a 2015 WHO statement. “Every effort should be made to provide caesarean sections to women in need, rather than striving to achieve a specific rate,” it further added.

The need of the hour, especially for Asian countries, is to formulate suitable regulations, ensure adequate funding for maternal healthcare services, such as accredited midwives, for instance. WHO proposes the Robson criteria as a standard for assessing, monitoring and comparing C-section rates within healthcare facilities over time.

“Unprecedented and unjustified” healthcare challenges take time and consistent effort to reach a resolution.