This article was published in India Today on February 11 2010
Reena, 20, was nine months pregnant but was not prepared to go through labour pains to have her first child. Her husband, who works in Dubai, concurred with her decision on opting for a cesarean section. Her doctor at a private hospital was more than willing to go by what her family wanted since it was a win-win situation. The patient wanted it, the hospital would get Rs 30,000 as a fee instead of the Rs 4,000 it charges for a normal delivery. Last month, Reena delivered a healthy boy without pain, thanks to a Cesarean Section (CS).
In places like Perinthalmanna in Kerala’s northern Malappuram district, there is nothing more lucrative than running a hospital. The 34-sq km town with a population of about 50,000 has as many as 400 registered doctors and 25 hospitals, including three with super speciality tertiary care facilities. Kerala, with the country’s largest health care network and the best health indicators, tops in the incidence of CS. The CS rate in Kerala is 30.1 per cent, thrice the national average. And unlike the rest of the country, there is hardly any major rural-urban difference in its incidence in Kerala. “Even developed countries like the US have reported figures around 25 per cent,” points out N. Ajith Kumar, director of the Centre for Socio-Economic and Environmental Studies, Kochi. Of the 7,500 childbirths at the the centuryold Government Women and Child Hospital in Thiruvananthapuram last year, 3,266 were by CS.
Studies from around the world have shown that an unwarranted CS leads to health risks to mothers such as injuries to uterus, bladder and also possibilities of severe infections, haemorrhage, and respiratory distress to babies. According to the protocol laid down by the WHO, medical intervention in childbirth is accepted only in cases of breech presentation, dystocia, previous CS and suspected foetal compromise, among others.
As in many places, the alarming rise in CS in Kerala is actually the flip side of major achievements the state has made in the field of public health. Be it life expectancy, rates of infant mortality, fertility, maternal mortality, in almost all indices Kerala not only tops the country but compares favourably with developed ones. Kerala has India’s top figures in providing its women the best in prenatal and post-natal care (see box). The state had achieved many of the UN’s Millennium Development Goals in the health sector and aims of the National Rural Health Mission more than a decade before its deadline of 2015. “The rise of CS in Kerala is the result of the advances it has made in the social sector,” says Usha Titus, state health secretary and a doctor. “But what is disturbing is the rise in the number of CS in government hospitals,” she adds. State Health Minister P.K. Sreemathi says, “The Government has proposed to explore ways to address the alarming rise in CS.” She believes that a stricter monitoring of private hospitals will have to be put in place, particularly to check the avarice of private hospitals and doctors.
Health experts point out various other factors for Kerala’s cesarean boom. Among them is the state’s low fertility rate due to the country’s widespread family planning methods. The state’s total fertility rate of 1.7 as against the national average of 2.7 has helped the state’s population growth go below replacement levels. “The fall in fertility has made a child very precious to parents and so they increasingly demand for CS the moment we inform them of even minimal foetal abnormality,” says Dr Lalitha Thrivikraman, chief gynaecologist at a leading hospital in Thiruvananthapuram. Another reason for doctors opting for CS is said to be part of “defensive medical practices”. The death of a mother or a newborn during delivery is said to be one of the main causes for litigation or even physical assault on doctors and hospitals by relatives. Thus, most gynaecologists are averse to taking any risk. Expectations of patients are very high these days and any dissatisfaction is expressed emotionally leading to assaults when a normal delivery goes wrong. Most doctors, however, discount the argument that CS is opted for painless delivery as newer types of anaesthesia are easily available due to which the argument is no longer valid.
While health experts believe regulation is called for, they admit it would not be advisable to transplant the parameters of western countries locally. K.P. Aravindan is a prominent public health activist and heads an NGO that advocates 25 per cent as a reasonable CS rate for Kerala. Strict controls, he says, exist only in Scandinavian countries and recounts a personal experience to oppose controls. His niece who lives in Norway was pregnant and doctors at the hospital in Oslo did not do a CS despite the baby being abnormally overweight. “The baby was born with brachial plexus injury. Now, all of us wish the delivery had taken place in Kerala,” he says.