Given the nature of maternity care, even the best gynecologist needs to be part of a team to deliver high-quality care during pregnancy, labour and delivery.
By Abhishek Bhartia
India is in the midst of a caesarean epidemic. And this problem is not just limited to the major metros. The National Family Health Survey (NHFS-4) found that caesarean rates of private urban hospitals across the states of West Bengal and Telangana were around 75 per cent! Research conducted by Sitaram Bhartia Institute has found that private hospitals in Delhi have a caesarean rate of 54 per cent, while government hospitals have a rate of 24 per cent, both well above the 10-15 per cent rate recommended by the WHO.
Women delivering in private hospitals choose their gynecologist and may pay upwards of a lakh for a delivery. Yet, too many of them end up with an unnecessary caesarean section that puts them at risk of serious complications in future pregnancies and interferes with their ability to breastfeed.
So, why is it that despite choosing trusted and reputed gynecologists, women run the risk of an unnecessary caesarean? Part of the reason may be their high-risk case mix, but the primary reason behind the trend is that even the best gynaecologists are caught in a system that leaves them unsupported.
Solo consultant practice
As gynecologists become established, their workload increases, often exceeding 15 deliveries in a month. In absence of a norm for shared practices, most gynaecologists work alone, running home clinics and delivering at one or more hospitals. The pressures of running a busy outpatient clinic, commuting in today’s traffic, and managing family and social commitments, makes it very difficult for them to give the time and attention that is needed by women in labour.
No junior doctors or skilled nurses for labour support
Compounding the time pressures on a gynaecologist is the fact that they may work in a hospital that doesn’t provide 24-hour support from a junior doctor. Sometimes, even when a junior doctor is available, that doctor may not have the skills required for attending to emergencies.
Skilled and empathetic nurses, who should provide continuous one-to-one support to every first-time mother in labour, are typically in short supply in most hospitals.
Without such support, the gynaecologist tends to be very anxious about leaving a woman in labour, lacking the confidence that they would be alerted in time in case of a complication.
Inadequate hospital facilities
Some hospitals don’t have the facilities to conduct an emergency caesarean at night; if they do have an operating theatre, they may not have a 24-hour on-site anesthesiologist or experienced neonatologists to attend to high-risk deliveries. In such cases, the gynaecologist is sometimes forced to take a decision for a caesarean during regular working hours, rather than wait for a normal delivery and risk an emergency situation in the middle of the night.
Women may also demand caesareans
Because of the lack of well-trained ancillary health professionals, most gynecologists find it difficult to have childbirth educators or offer antenatal classes at their clinics. Without proper antenatal education, women often feel unprepared for labour and may not fully appreciate the risks of a caesarean section. Undoubtedly, this largely explains the phenomenon of on-demand caesareans in Delhi.
Is it sufficient to identify the best gynecologist?
Given the nature of maternity care, even the best gynecologist needs to be part of a team to deliver high-quality care during pregnancy, labour and delivery. During pregnancy, they need to work with antenatal educators who can answer the myriad questions that a woman has when she first becomes pregnant.
During labour and delivery, which can take up to 24 hours for first-time mothers, they need a good junior doctor and nursing support, and a hospital with round-the-clock facilities and specialists. They also need other consultant gynaecologists who can step in when they might be occupied elsewhere.
Choose a team not just a gynaecologist
So, if we want women to experience natural childbirth, with caesarean section being reserved only for those with clear medical indications, it is essential that we shift our mindset. Instead of searching for “the best gynaecologist in Delhi” we should enquire about the team of gynaecologists and a hospital that can deliver unhurried and supportive care that is required for a safe and memorable childbirth.
(The writer is Director, Sitaram Bhartia Institute of Science and Research.)