C-section choice more about hospital than patient: study

High count of caesarian births has more to do with character of hospital than needs of patients.

Written by Anuradha Mascarenhas | Pune | Published: April 11, 2013 3:02 am

A high count of caesarian births has more to do with the character of the hospital than with the needs of the patients,according to a study by the Harvard School of Public Health. From hospital to hospital,the same woman would have a different chance of undergoing a C-section,say the researchers,who feel their US-based study has wide significance across developing economies too.

“There have been recent reports of increase in caesarian deliveries in India and it is important that systematic monitoring and standardised protocols are developed so that unnecessary caesarian deliveries are avoided,” said S V Subramanian,professor of population health and geography at Harvard University.

The study,by researchers of Harvard SPH and the Massachusetts Department of Public Health,was published online last month in PLOS ONE.

“Even after taking into account factors that put women at risk of having a C-section,such as age,and pre-existing health conditions,some hospitals still have higher rates of C-section delivery than others,” said Subramanian,senior author of the study. “Put simply,for two women with a similar observed risk profile,one might have a C-section delivery and one might not,depending on which hospital they go to.”

The study provides the strongest evidence yet that it’s not just medical need that decides who has C-sections,but also something at the hospital level. “This is the first time that anyone has shown this problem exists in Massachusetts,which is widely considered to be one of the world’s premier health care hubs,” said co-author Mariana Arcaya,research scientist at the Harvard Center for Population and Development Studies.

C-sections can be a lifesaving procedure for an infant in distress,or when there are multiple births or other labour complications,but C-sections that are not medically necessary can put mothers and babies at avoidable risk of infection,extend hospital stays and recoveries,and increase health costs.

C-section rates have been increasing in the US over the past 17 years. In Massachusetts,they acounted for about one-third of all births in 2009.

Though this study did not pinpoint which hospital factors were at play,the authors highlighted previous studies suggesting that liability and insurance,admission practices,and the number of midwives present may influence C-section rates. Lack of clinical guidelines or standards on when a caesariansection should be performed,too,may help explain why hospital rates are so variable.

There are no standard guidelines in India either,says Dr Hema Divakar,president of the Federation of Obstetric and Gynaecological Society of India.

The threshold for deciding a C-section over normal delivery is very low,especially when the patient is elderly,has a co-morbid condition or has had pregnancy through an assisted process,Divakar says. The country has 27 million deliveries every year. With 12 -16 per cent of pregnant woman developing gestational diabetes during pregnancy,they are often treated as high-risk.

There is no documented evidence on the number of C-sections in India. Dr P K Shah,former president of FOGSI,says these have risen. “In 1984,when I was at Sion Hospital there were barely 7-8 per cent C-section deliveries,” Shah says. “Now the rate of C-sections at a government hospital such as KEM at Mumbai is 25 per cent.”

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