In India, the growing trend of performing or opting for Cesarean deliveries is a crucial thing to ponder upon. However, in recent times the issue has been discussed quite a number of times at both Global and National Levels. It is to be noted that necessary surgical interventions during delivery of complicated cases bring down the level of morbidity and mortality. However, The World Health Organization in its statement on Cesarean delivery rates said that anything above 10%-15% mark no longer serves in bringing down mortality (WHO, 2015). A study by Betran A, Y Jianfeng et al, in 2016 estimated that Latin America & the Caribbean region has the highest cesarean section rates (40.5%), whereas Asia stood at 19.2%. Globally, there was an increase of 12.4% between the years 1990–2014 with an annual increase of 4.4%. Is it to be noted that Asia was the second largest continent to show the largest absolute increase.
In 2010, a report released by the WHO had sorted the list of countries showing cesarean rates below 10% for 2008 and percent of cesarean sections needed for the year. India then had only 8.5% of the cesarean section with a need of 12.7%. (World Health Report, 2010). All the above numbers show that India has been surpassing the rates in recent times.
There is an indeed a far cry around the world on the increased rate of cesarean deliveries resulting in complications in maternal health especially perinatal & maternal morbidity. The reasons for such a high rate is attributed to several complex factors like late pregnancies, specific birth time conditions, financial duping by some doctors, birthing trends, lack of midwifery support, high-risk pregnancies, delivery fears, etc.
Coming back to India, according to the fourth round of National Family Health Survey, 2015–2016 the rate of performing cesarean deliveries is at 17% with interstate disparities making the picture more demeaning. In all, there are 9 states which have more than 30% of c-section deliveries. A study by Guilmoto C, Dumont A in 2019 revealed that the doubling of a cesarean section from the last decade is related to the simultaneous decline in the number of home deliveries without any medical supervision. Further, it explained that in the future too with better access to health facilities, low fertility, rising prosperity etc. will lead to more cesarean deliveries.
Telangana, a newly formed state of Southern India has a very high rate of cesarean deliveries at 57.7%. Nagaland, on the other hand, has only 5.8% c section deliveries according to the survey. In Telangana, the deliveries conducted at private facilities was as high as 92%, the rate of the cesarean section also stood at 74.5% at private facilities. However, with the introduction of midwifery care in public facilities could bring the high level of c-sections down by promoting vaginal deliveries.
India is seen to have a huge disparity with respect to the rate of c section deliveries. Urban settings tend to have a larger share in cesarean deliveries as compared to rural settings. Similarly, private health care settings have seen a larger footfall as compared with public health care settings. According to the numbers from the survey, the people going for public and private facilities for conducting a cesarean delivery was around 11% and 40% indicating high expenditure incurred on it. Even the numbers vary when observed from the wealth quin-tile perspective. It ranges from 4.4% to 35%.
According to the latest round of National Family Health Survey -5 Phase 1, states like Andhra Pradesh, Jammu & Kashmir and Telangana have more than 40% of their deliveries conducted through caesarean section. Telangana has the highest percentage with 60.7 (58.4% in rural areas & 64.3 % in urban areas) % of C-section deliveries.
Although it is important to note that paucity of data reflects a lot on the scientific speculations made on the connections between the high rate of cesarean deliveries and mortality, however, quality of care and safety becomes important in the analysis of c section delivery rates. While taking care of the quality and safety in c section deliveries, it is important to take an account of the growing burden of Anti-microbial resistance globally. To put simply, Antimicrobial Resistance is a growing challenge for the entire health community where there is resistance to drugs that otherwise treat infections. Here what is interesting to note is that mothers and newborn babies die during the delivery due to infections.
There is no doubt on the fact that cesarean deliveries involve the risk of infections which are dangerous in nature, what happens if those infections become untreatable due to antibiotic resistance. Thus overuse of surgical interventions leads to more risks and morbidity.
To breach the intention of doing unnecessary cesarean deliveries it is always healthy to promote a normal or vaginal delivery. Induction of labour in normal pregnant women leads to more cases of cesarean deliveries, as reported by a study. Further, if the inductions could be minimized, they can lead to reduction in the number of C-sec deliveries. Secondly, Midwifery operations which are also a cost-effective intervention on this, is a great way to go about. A report by the Ministry of Health & Family Welfare on midwifery services claimed that where 85% of pregnancies do not require specialized obstetric interventions, midwifery-led care plays a vital role in promoting physiological births thereby reducing overmedicalization. (Midwifery services in India, 2018). The importance laid on the midwifery support and services by the government is surely a good way to reduce the unnecessary burden.
Countries like Sweden and Sri Lanka have given complimentary roles to midwives in maternity care & are backed by a good referral system thereby improving the maternal health indicators of the country.
A lesson to learn from China!
Wenzhou in China is also focusing on reducing the number of cesarean deliveries on maternal request & by policy interventions as revealed in a study . It is exciting to know that China in recent times have managed to control the rate of cesarean deliveries at a considerable rate. In 1993, when it was mere 5% rose to 40%-50% in 2010 and as high as 70% in some urban areas, efforts were put in in terms of health promotion, strict hospital regulations and practitioner training, and other changes in reproductive counselling.
However, India with its new guidelines on midwifery services, 2018 included an introduction of the midwifery model of care for normal birth in midwifery-led places of public health facilities. But the question that arises here is what happens to the unnecessary surgical deliveries conducted at private facilities as it is clear that private facilities account for most of the c-section deliveries in India.
Our country is yet to come to up with any recommended rate for performing surgical interventions during delivery. There are several factors affecting the rate at different levels; namely personal, health care provider level and at the community at large which needs to be taken care of. Adopting WHO guidelines on reducing the burden of C-section could be one way of looking at it i.e. conducting clinical workshops to address the fears and pains of mother, couple-based prevention programs, consultation in the form of taking a second opinion, equalizing fess for both vaginal delivery cases or cesarean cases in order to reduce unnecessary numbers. Recent Cochrane systematic review on using non-clinical trials to reduce unnecessary cesarean section deliveries reveals that childbirth training workshops can reduce c-sections and increase vaginal delivery.