C-section: choice or compulsion?

I had my first baby two years ago in Karachi’s renowned private hospital. After the delivery, I was lying numb, exhausted, eyes swollen telling the tale of the trauma I just faced in the labour room. The utter insensitivity and maltreatment of inexperienced and frustrated staff left me feeling vulnerable,” shares Paras Sundus, a 24-year old mother. “I believed in my doctor and the hospital management but I was very disappointed. I was exploited not only mentally but also physically. The nurses were callous and told me that they weren’t allowed to proceed until the doctor came. Meanwhile, they kept passing snide remarks and asking me to agree for the operation as that was the only way to get rid of the unbearable pain. I had to say yes after which the nurse called the doctor to operate me,” she adds.

A report by WHO released in 2015 states that C-Section should remain 10 per cent to 15 per cent in a country. It should only be considered if there is a medical emergency or a fatal risk - risk to mother or baby’s life, hypertension or diabetes in mothers, etc. The number of C-Section has multiplied throughout the world. From 2003 to 2018, there has been a 21 per cent increase of C-Section globally.

According to an analytical retrospective study conducted at Aga Khan Women Hospital, Karachi, and published in Journal of the Pakistan Medical Association (JPMA) in January 2015, from October 2011 to September 2012, 3266 deliveries were performed in the hospital among which 1021 (31.26 per cent) were CS, 365 (11.1 per cent) had a history of CS and Vaginal Birth (VB) trials were given to 33 (9 per cent) of them and only 21 (63.6 per cent) of them could deliver naturally.

A recent study on the rising number of CS in Pakistan was published at PLOS.org (Public Library of Science) on October 17th, 2017. The study said: “C-Section rates were found to have increased during this period, with an especially significant rise from 2.7 per cent during1990-1991 to 15.8 per cent during 2012-2013 with lower utilisation among the uneducated women (7.5 per cent), compared with the women with higher education (40.3 per cent). C-section rates ranged from 5.5 per cent among the poorest women to 35.3 per cent in the richest women. Only 11.5 per cent of the rural women had a C-Section compared to 25.6 per cent of the urban women. A greater likelihood of having a caesarean section was observed in the richest, highly educated, and urban-living women while there was no significant difference observed in caesarean section rates between the private and public sectors in all three surveys. To improve maternal health, routine monitoring and evaluation of the provision of emergency obstetric services are needed to address the underuse of C-Section in poor and rural areas and overuse in rich and urban areas.”

Similarly, Rehana Sheikh, mother of three recalls the horrors of her first major surgery, “My first CS was performed in 1996 and it was completely unexpected. The pain from the stitches kept on getting worse instead of subsiding; and all this happened because no skin test was done prior to iodine application on my stitches. I complained about it but the doctor deemed it as a non-issue. I couldn’t stand up or walk properly for months because that wound took ages to heal. I still feel intense pain in my stitches even after 20 years.”

While there can be risks to the mother after they have had a C-Section including infections, surgical injuries to bladder, loss of blood, complications in future surgeries, postpartum depression etc but there are some cases that have no complications. Case in point, Laiba, a working woman and mother of four states, “I had my first C-section because my water broke and the doctor waited for good 12 hours until we finally agreed for the surgery. After my first, I had three more C-sections and all were anticipated and smooth.”

Nazia Sheikh, a senior gynaecologist at a private hospital sheds light on the matter, “It’s not just that the hospitals are performing C-Sections like butchers but there are also young girls who opt for the surgeries for uncomplicated and painless delivery. I recently had performed a C-section because the mother was migrating to another country, so she decided to go for an operation in the 38th week. There were no complications and it was a smooth procedure for the mother and the baby.”

According to a recent survey and research, the rates of C-Sections are higher in private clinic and hospitals than in the public or government hospitals. A country’s culture and family status also plays a crucial role. The poor families cannot afford the expensive surgeries, bills and medicines. Whereas, the rich families consider private hospitals to provide more personalised care to the mothers, maintain hygiene, state-of-the-art and comfortable rooms and availability of technical facilities. The doctors let a mother stay in the labour room for 3 to 24 hours - depending on her tolerance of contractions - and suddenly an emergency is announced that puts the baby’s life in danger hence C-Section becomes a Hobson’s choice. This has become a pattern almost in all the countries through which private hospitals are earning.

“I have been a part of two famous and old Government hospitals in Karachi. In my practice, I have performed Natural Birth (NB) in the Government hospitals whereas uncountable CS in private hospitals,” says Raheela Lakhani, a young gynaecologist. “The percentage of CS is almost below 20 per cent in the public sectors. Not all private hospitals are ready to bring the mothers under the knife, but there are serious factors involved which lead to CS that also includes intolerance of young mothers towards contractions. You can’t keep check and balance on every private clinic that is opened in every corner of the street,” she adds.

To lessen the increasing percentage of C-Sections all over the world, WHO has introduced numerous methods including Robson Classification System to monitor the rate of C-Sections worldwide. Yet, there is still a lot of strategy and planning needed to execute the system. While there are a few countries that have complete data but countries like Pakistan still lack proper and complete information regarding the number of CS.

Dr Baloch, who is an ex- District Health Officer and served more than 30 years in the medical industry of Pakistan, explains, “CS is difficult for a Government hospital to perform as there are limited number of beds and a gynaecologist at a Government hospital would like a patient to leave after delivery as soon as possible. The doctor usually has to go to her private hospital where she does her business by lining up patients for CS. Private hospitals are commercial and all the doctors who practice in Government hospitals would want their patients to come at the private hospital where they charge from 2000 to 3500 per visit leading to the cost of C-Section 100,000 and above.”

Dr Baloch also highlights an alarming deception that some hospitals practice, “In Government hospitals, the doctor uses dose of oxytocin that is injected in the drip to increase the pains and contractions that helps a mother for NB. Doctors even correct the breach position by massaging the abdomen of mother. Whereas in private hospitals, the amount of oxytocin injected in the drip is underdose in which the mother feels the pain only and but it doesn’t aid to deliver naturally. This act is done to show the mother that the oxytocin isn’t helping her deliver the baby naturally so leaving CS as the only option.”

The unprecedented rise in the proportion of C-Sections has reached at an alarming stage. The chaos created in the labour room for the mother and her family is beyond imagination. In order to address this issue, strategies should be made and combined actions should be taken with the Government to keep a track on the hospitals, implementation of yearly data submission on the number of CS and NB performed. Awareness campaigns should be spread among young women to educate them about the repercussions of CS and let them make an informed decision. Hopefully, this will help to set the natural wheel back in motion.