A study in JAMA Network Open throws the spotlight on the rapid growth of caesarean section births in India.
Call for monitoring
“The proportion of births delivered by cesarean delivery has increased especially fast during the last decade in India, reaching 17.2% in 2010 to 2016 according to the NFHS-4 survey. This level is already higher than that observed in some industrialized countries in Europe such as the Netherlands or Finland. The emerging situation also points to significant regional and sex disparities, with a substantial deficit of cesarean deliveries among underprivileged groups and almost 2 million excess cesarean births every year among more advanced sections of the population. The need to monitor the further progression of cesarean rates is urgent,” the paper states.
The researchers list changes in lifestyles, commercial pressure, and cultural factors as some of the plausible explanations for the rise. At the same time, they highlight the importance of making both women and medical professionals aware why C-Sec is not a commercial or lifestyle choice but a medical one.
India’s annual birth rate is 2.64 crore per year. The paper flags the growth in C-sec rate to 17.2%, which is above the World Health Organization’s recommendation. In a statement in 2015, WHO said: “Since 1985, the international healthcare community has considered the ‘ideal rate’ for caesarean sections to be between 10% and 15%. New studies reveal that when caesarean section rates rise towards 10% across a population, the number of maternal and newborn deaths decreases. But when the rate goes above 10%, there is no evidence that mortality rates improve.” If caesarean rates are below 5% in a population, WHO suggests it indicates a problem in healthcare access.
The new study says the current cesarean rate corresponds to an estimated 4.38 million births per year between 2010-16. The change during the last decade corresponds to an annual rate of increase of 7%, almost twice the rate observed in the world, it says. While China had 5.3 million cesarean births in 2008-2014, the cesarean rate is reportedly contracting. In a matter of years, the study estimates, India will become home to the largest number of cesarean births.
NFHS-4 data show an institutional and regional skew — 40.9% of babies in private hospitals are born through C-sec as compared to 11.9% of those born in government hospitals. The C-sec figures range from 87.1% of deliveries in private hospitals of urban Tripura (against 36.4% in government sector) to 25.3% of private hospitals in urban Haryana (10.7% in government). In Tripura, the overall government-private gap was 73.7% to 18.1%.
Public health experts the world over agree that C-secs save lives. Yet last year, WHO released a document underscoring its concern about rising C-section rates, while there remains a section of women who do not get it when they need it. “Caesarean birth is associated with short- and long-term risks that can extend many years beyond the current delivery and affect the health of the woman, the child and future pregnancies. These risks are higher in women with limited access to comprehensive obstetric care. Caesarean sections are also costly, and high rates of unnecessary caesarean sections can therefore pull resources away from other essential health services,” WHO said.
In 2011, the UK National Institute For Health And Care Excellence listed a set of guidelines. Among the conditions listed as warranting a C-sec are multiple pregnancies, premature birth, and when there is a risk of mother to child transmission of infection.
Behind the growth
Caesarean packages can range between Rs 9,000 (approved rate under Ayushman Bharat -PMJAY) to well over a lakh in some of the swankier hospitals. That is why C-secs under PMJAY can be reimbursed only if they happen in government hospitals or are pre-authorised by the competent authority to be carried out in a private hospital.
Doctors often say that a non-medical C-sec decision is taken at the behest of the mother or the family. There are also mothers who want their babies to be born on a particular day or a particular time, leading to a C-sec. There are others who are reluctant to go through protracted labour and want to get it over quickly.
According to a paper by the International Union for Scientific Study of Population: “… Unnecessary caesareans generate higher expenditure at individual and national levels and have the potential to divert human and financial resources from higher priority intervention… In 2008, the cost of the global excess/unnecessary C-section delivery was estimated approximately $2.32 billion.”