WHY SO MANY CAESAREAN DELIVERIES NOWADAYS ?
I started my studies as a Gynaecologist in 1981 and completed my M.D. post graduation in 1984. Soon I started my private practice as well. During these years of my practice of 37 to 38 years, I used to be surprised and saddened by the dramatic increase in the number of cesarean deliveries during these 37-38 years.But when I started a scrutinising my records of so many years, (nearly 15000 births), some very important factors came to light which I would like present here in nutshell.
Factors responsible for altered patterns of childbirth.
1. ‘Age of first pregnancy’ – change in the age of marriage and the age of having a first child – This is a very important factor. The average age of a woman’s first delivery amongst all my deliveries during the previous 20 years was 23 yr. While in the last 17 years data shows it is 27 years and 6 months. Also during the same period, 19% of women used to get pregnant below 20 years of age whereas today that number is only 5%. As age advances, women’s reproductive organs and the muscles around the vagina change and become tighter and less elastic.This makes more difficult for the baby to slide down, and increases the chances of foetal distress or non progress of labour, resulting in more caesarean deliveries.
2. ‘Nutrition’ – Change in giving good food and good medicines to the mother from early pregnancy leads to better nutritional status for foetal growth. Its body grows more than otherwise naturally possible to its mother’s genetic and physical capacity. Also, calcium in the bones of its skull increases to a good extent. In earlier times, a pregnant woman used to make her first visit to a maternity doctor after 6 months of pregnancy. Therefore, if there is malnutrition at her home during the first seven months, she will have a relatively smaller foetus which will facilitate normal delivery. As a result birth weight as well as nutrient storage will be lower than the woman who starts proper nutrients from the beginning of pregnancy. Earlier (first 20 years of all my deliveries) average baby weight was 2.700 kg. which has now (last 17 years) increased to 3 kg. Earlier the percentage of all the deliveries of women with lower haemoglobin(anaemia) was less than 10 gm was 36% which has reduced to less than 15% in the last 17 years and in the last 5 years it is 7% only.
3. ‘Number of children and their family value’ – Compared to the earlier years when the average family had three-four children, now every family/couple prefers one or two children. Naturally, therefore, assessment of each child’s health and potential becomes extremely important. Also, due to infertility or late marriage if pregnancy has occurred after treatment, doctors as well as family considers this as a precious pregnancy and take least risk with respect to childbirth. Hence caesarean deliveries increase.
4. ‘Early sonography’ – Due to the availability of sonography facilities from the very early pregnancy, parents and doctors are aware of minor issues concerning the foetal or maternal health.If there is any problem in either, the chances of early caesarean delivery increases, as waiting till natural labour pain starts might be risky. Sonography colour doppler gives more clear information about the baby’s blood circulation. Due to this, India’s neonatal and perinatal mortality rate, which occurs in the womb or six weeks after delivery, has reduced rapidly over these years.
5. ‘Entrapment of the umbilical cord in the baby’s neck’ – During my earlier 20 years only 6-7 out of 100 babies were having one or two loops of umbilical cords around the neck on sonography. (I have been doing regular sonography of all pregnancies since 1983). In the last 17 years, 60-70% of the babies have one or two umbilical cords around the neck at the 9th month of pregnancy. The baby is more and more active in the womb due to the current noise polluted environment or some other reasons. This increases risk of normal vaginal delivery for the baby and women more often undergo caesarean delivery.
6. ‘More knowledgeable pregnant woman and her family’. – Every woman and family member has become much more informed about pregnancy and childbirth than before. Apart from their own doctor, they get information about the risks of pregnancy through the internet or through the advice of other doctors. Therefore, from the very beginning, doctors are advised to do childbirth without any risk. This can increase caesarean delivery rate.
7. ‘Women’s Freedom and Personal Choice of Childbirth’ – Today’s women decide for themselves whether to endure the pain of childbirth or not. Earlier pregnant women used to be more submissive and bear the pain silently by respecting their elders. Now the doctors cannot go beyond the will and wish of the pregnant woman.
8. ‘Consumer Court Laws and outrage against Doctors and hospitals’ – Ever since doctors and hospitals have been placed at par with other service providers and business organisations in consumer courts, doctors and hospitals have been more and more cautious in taking decisions whereby they do not put themselves at risk. Also, many doctors and hospitals have had to suffer the outrage of the patient’s relatives and improper handling by legal machinery when the outcome of pregnancy is not favourable in spite of no faults of the doctor or hospitals. Obviously doctors and hospitals prefer caesarean section instead of normal delivery when there are any high risk factors.
9. ‘First delivery by caesarean section’ – Women whose first delivery was by caesarean section require extra vigilance and awareness for a normal second delivery. Doctors and family members are often not ready to take that risk.
The above nine reasons are the main ones leading to more caesarean deliveries. Amongst the less important reasons are
1. Problem of giving time for normal delivery by a very busy doctor or very elderly doctor.
2. Problem of lack of good/trained/qualified nursing staff for the day as well as night duties in the hospital.
3. The problem of non-availability of blood or blood products when the patient needs them. The Government of India does not give permission easily to new blood banks. At so many places there are problems getting blood from the right group in an emergency.
4. The problems caused by not getting a paediatrician and an anaesthetist doctor in time if needed in the hospital.
5. Lure of financial gain to the doctor or hospital performing caesarean section. Due to such many reasons, the rate of caesarean section has increased not only in private settings but also in government hospitals, not only in India but in every country of the world. An average of 35-55% of deliveries are by caesarean section. Government hospitals are more likely to take higher risk as they have a bigger team of qualified doctors and staff, trainee doctors have to learn, patients are financially weak, patients are less likely to take legal action, availability of blood bank facility and NICU facility for newborns. Some other points to understand are
1. Complications of caesarean operation are much less than before. Because good instruments, good drugs and good suturing materials are available everywhere.
2. Due to more caesarean deliveries and better facilities for the treatment of newborns, the rate of newborn deaths in India has decreased drastically.
3. Mortality rate of India 1969 – Neonatal Mortality Rate – 86
2020 Neonatal Mortality Rate – 20
1990 Under five mortality rate -125
2020 Under five mortality rate – 36
4. Fewer births and more caesarean births result in less damage to the uterus and lower part of women, which has reduced gynaecological problems of women like genital prolapse, voiding problems and urinary leakage.
5. Unless hospitals and doctors are taken out of constant threat by consumer courts and an improper medico-legal environment in the society, there is little chance of a reduction in caesarean delivery rates.
Dr. Jagdip Shah
M.D., D.G.O, M.C.P.S.
In practice since 1984.