Dr ADS Manhas
Caesarian Section delivery is a life saving surgical procedure for mothers and babies when certain complications appear during pregnancy or labor. Perhaps the first written record of mother and baby surviving a Caesarian Section comes from Switzerland in 1500 when carpenter, Jacob Nufer, performed the operation on his wife who after several days in labor was unable to deliver her baby. Numerous references to Caesarian section appear in ancient Hindu, Egyptian, Grecian, Roman, and other European folk lore and texts.
Caesarian Section is a surgical procedure to prevent maternal and neonate mortality in case of medically indicated reasons, it is life saving procedure for mother and baby but this procedure can lead to short and long term health risks for women and children. Caesarian Section rates have increased throughout the world in last few decades. As per WHO , Caesarean section rates have risen from around 7% in 1990 to 21%” in 2021 and is projected to continue increasing over this current decade, with nearly a third (29%) of all births likely to take place by Caesarean section by 2030.
Caesarian Section Rate in Jammu & Kashmir is 42.7% as per National Family Health Survey (NFHS-5), while urban areas of J&K report 54.7% C-Sections and rural areas report 38.7%, and Private Health Institutions in J&K reported 82.1% C-section rate.
This global surge in C-sections is reflected across most states and Union Territories of India, with an increase in these deliveries, as per the most recent National Family Health Survey (NFHS-5). The national C-section delivery rate is at 21.5%, which is higher than the ideal range of 10%-15% recommended by the WHO. The recommendation is based on findings that a lower C-section rate could mean unnecessary deaths of mother or child, while a higher percentage would mean no added benefit in terms of reduction in the number of maternal and new-born deaths.
There are several risks associated with elective C-Sections, including of iatrogenic infections, ectopic pregnancies, even miscarriage. C-Sections also pose a 2.84-times higher risk of maternal mortality than after vaginal births. Mothers electing for C-Sections also endanger subsequent pregnancies and reduce the chances of vaginal deliveries in future and complications in subsequent pregnancies such as uterine rupture, ectopic pregnancy, and hysterectomy. Risks for babies include being accidentally receiving cut by the surgeon’s knife, increased prevalence of allergies, childhood obesity, respiratory distress and lower gut-microbial diversity.
However, in urban areas, this has become common procedure as a result of two factors: financial, as gynecologists charge extra for C-sections and often counsel patients to go for it, and the social aspect, as a majority of the women, who are from the higher socio-economic status prefer C-section over natural birth this practice encourages other women also to choose C-sections because someone known to them had undergone, thus there is increase in demand for C-sections by women.
The similar trend is now being followed in public hospitals and there is no accountability for the same. “Government should intervene and fix responsibility of doctors. Moreover, there should be proper audit of normal and C-Section deliveries in the health institutions, both public as well as private and action should be taken against those doctors who unnecessarily go for C-Section deliveries.
One of the main reasons for the rise in C-section deliveries in the developing countries including India is lack of access to proper maternal healthcare. Women particularly those living in rural areas, face significant barriers to accessing healthcare services, including lack of transportation, financial constraints, and cultural barriers. These factors make it difficult for women to receive the prenatal care they need to ensure a safe and healthy delivery.
Another, contributing factor to the rise in C-section rates is a lack of trained healthcare providers. Many healthcare facilities in the country lack the personnel and resources necessary to provide safe and effective obstetric care, including skilled birth attendants and access to emergency obstetric care. This shortage of trained healthcare providers in obstetric care can lead to inappropriate use of C-sections by Consultants in Obstetrics and Gynae working in Public sector and they also opt for the procedure to avoid unnecessary calls during night or during their private practice. It has also been observed that Obstetrics & Gynae Consultants working in Public sector, encourage their private patients to undergo C-section at Private Hospitals as they are employed in the Public Healthcare Delivery System during the day time.
Previously, women were more active physically even close to their deliveries, and therefore the delivery was comparatively easier. Further, modern life has increased stress and pressures due to changing lifestyles, thereby significantly affecting women’s hormones. Absence of a consistent support system, knowledge of personal care and improper dietary habits particularly during pregnancy, has adverse impacts on the maternal health of women.C-sections are also linked to the fact that women marry later in life than they used to, and this puts pressure on them to become pregnant. This pressure in turn leads to their undergoing various fertility treatments. And when they do get pregnant, they worry that natural delivery might adversely affect the health of their precious child, and end up asking for a C-section. Patients’ preference is a major cause for the spike in C-section deliveries. “Some patients, mostly with a history, believe that the vaginal deliveries could pose a threat to their lives and that of their babies, and opt for C-sections instead. Another reason why women prefer C-section over natural delivery is that their capacity to bear pain has decreased significantly. There is need for early sensitization and behavioral change communication for pregnant women to motivate them towards natural deliveries, it is necessary for making the pregnant women and families understand the merits of normal delivery, since in many cases patients themselves opt for C-section instead of a normal delivery.
It’s also important to create awareness among women, on the risks and benefits of C-section so they can make informed decisions. Additionally, it’s important to have a community that supports natural birth as much as possible and create an environment where it is seen as a normal and healthy process.
To address the alarming rise in C-section rates in UT of Jammu & Kashmir, it is important to improve access to maternal healthcare and increase the number of trained healthcare providers in the region. This can be achieved through a number of measures, including increasing the number of healthcare facilities and clinics, providing transportation to and from healthcare facilities, and imparting obstetric care training to MBBS MOs and Skill Birth Attendant training to ANMs/ Staff Nurses and other Para-medical staff and educating local healthcare providers on best practices for maternal care. By improving access to maternal healthcare and increasing the number of obstetric trained healthcare providers, it can be ensured that mothers and babies have the best possible outcomes during delivery.
Some of the other measures and interventions which can be adopted are “High Risk Pregnancy Identification” to identify those requiring more care during early-stage pregnancies, One of the ways in which it can be addressed is through ASHA workers who can counsel women and families, prepare them for normal deliveries, educate them about breastfeeding and complementary feeding, teaching them about family planning, immunization, contraception and prevention of common infections, including Reproductive Tract Infection/Sexually Transmitted Infection, as also teaching expecting mothers how to care for their newborn babies. Ensure screening of all High risk pregnancies and once high risk pregnancy is detected; patient should be under the care of Consultant of Gynae & Obs. There should be well defined protocols for referral linkages to higher Health Institutions.
Another priority area is improving midwifery services, focusing on addressing existing issues by promoting quality, continuity of care through provision of women-centric care and promoting natural birth improving the ratio of cases to doctor to be more equitable in order to reduce the burden on doctors. The expectations of people at the time of delivery sometimes places undue burden on the attending doctors and to avoid any unpleasant result (during normal delivery), as patients attendants always blame the doctor for negligence, and this pressure also leads to doctors opting for C-section.
Empowering expectant mothers by Antenatal education on natural birth process, stages of labor, and providing psycho social support through health workers and Prenatal education of the husband of the pregnant woman about the benefits of normal delivery for both mother and the new born.
It is equally important to involve prominent women including PRIs/ women leaders in propagating the benefits of normal deliveries and sensitize the general public through IEC awareness, there is also need to educate the girl child in Schools and Colleges/ Universities about the benefits of normal deliveries and educate them about RTI/ STI.
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