When Bangalore-based singer Sukruthi Ajaykumar experienced pain in her lower back, her doctor asked her to come in for a check-up. Around 37 weeks pregnant, she was still over 20 days away from her due date. So far, all her tests were normal. At the hospital, her doctor, who she had been seeing throughout her pregnancy, said that she will do an internal check - a pelvic examination.
Back in 2016 when the incident occurred, Sukruthi did not know she could refuse a pelvic exam, she was hesitant to even ask questions. “The doctor inserted her gloved fist inside my vagina, took it out and showed me her fist covered with blood. I freaked out,” she recalls. “The doctor said that I could go home if I wanted to, but also that I would come back in a week with similar or more intense pain. I was confused,” she recalls.
She says she was advised to undergo a C-section. She wasn’t told whether it was a precautionary measure or whether her baby’s life is in danger, she alleges. Sukruthi was told that she needed to be kept in the hospital under observation for a few days. Then the hospital staff reportedly told her that the next day, which was a Friday, was auspicious for the baby to be born. “They urged me to schedule a C-section birth then.” The medical costs at the private hospital where she was being cared for was covered by her husband’s health insurance.
Births by a thousand cuts
A C-section, or caesarean section, is the delivery of a baby through a surgical incision which is made in the mother's abdomen and uterus. A C-section could be scheduled in advance or be needed due to a medical complication during surgery. The World Health Organization calls C-section as one of the most commonly performed surgical procedures in the world.
According to the body, when C-section rates rise and reach close to 10%, or one in every ten births, maternal and infant deaths drop. The procedure can be life-saving in case of complications. Scientific evidence suggest C-section push up both maternal and infant mortality and is not an option that must be taken lightly. India’s maternal mortality rate is nearly four times that of its neighbor Sri Lanka. One-fourth of the world’s infant deaths happen here. So C-Sections can help women immensely when natural birth gets painful and life-threatening. But when this rate rises above 10% in a population there is no evidence to show that it helps the mother or the newborn. It does not recommend putting a mother’s body through a major surgery intervention unless there is a need to do so.
New mother being counselled about lactation at one of Bangalore Birth Network's Lactation Programme at a health centre
In Karnataka, four out of every ten births in private hospitals are a result of a C-section. In Telangana, seven out of every ten deliveries in private hospitals will end in a C-section birth while six out of every ten deliveries in a private healthcare set-up Andhra Pradesh will meet the same fate, according to government data.
Across the states of Karnataka, Kerala, Tamil Nadu, Andhra Pradesh and Telangana the rate of C-section deliveries is two to six times higher than what is recommended by the WHO. What is also clear is that the rates are higher across the board – public-private and rural-urban divides notwithstanding.
Nearly two out of every ten births (17.2%) in India occurs via a C-section delivery. A breakdown of public and private sector shows that the rates of C-section in the private sector is double than the public sector.
The high number C-Section surgeries prompted Mumbai-based researcher Subarna Ghosh to start an online petition. Having been through a C-section herself, Ghosh made a simple demand to the government: Make it mandatory for all hospitals to declare the number of natural and C-section births taking place in their hospital online. “Greater transparency makes a difference,” she insists.
Her petition did not just garner media attention but was also signed by over 3.5 lakh individuals. Soon, hospitals empanelled under the Central Government Health Scheme (CGHS) that provide health services to central government employees and their dependents, were asked to display their C-section rates at the front desk, or risk losing being a part of the scheme.
Subarna Ghosh
Ghosh is of the opinion that while both public and private hospitals need to be monitored, real change will have to be driven by doctors themselves. “FOGSI (The Federation of Obstetric and Gynecological Societies of India) has to be co-opted as the doctors are the ones whose involvement will make a huge difference.”
Why doctors rush into surgery
Dr Evita Fernandez, obstetrician and MD of Fernandez Hospital in Hyderabad in 2002 was one of the first institution heads to start being transparent – long before Subarna’s petition. “When you are transparent and look at the statistics, they hit you. You start changing your practice,” she reasons.
The patients are divided into high-risk and low-risk groups depending on their health status during pregnancy. While the C-section rates for high-risk group can go up to 35% in some months, Dr Fernandez and her team manage to keep the rates for the low-risk groups either below or hovering around the recommended 10%.
But, why are the rates high at all?
Commercialization of the birth industry is a key change in recent years - both rural and urban areas. C-sections are lucrative both for the doctors and for the hospitals with women often not being given the choice to decide. International studies point fingers at the private hospitals for the high rates, especially in poor areas where there aren't enough public health facilities or the choice to opt out. “Some hospitals are very commercial,” Fernandez explains. The beds have to be filled, the hospital infrastructure needs to be put in use and patients with medical insurance report being made the scapegoats. While scheduled C-sections are convenient for the doctors one cannot jump to conclusions without knowing the specifics of the case.
“There are also too many unnecessary surgical interventions, a trend which a Lancet report termed as too much, too soon,” explains Ghosh.
“In Kerala, doctors in three different cities told me that they fear vandalism by patients if something goes wrong during a delivery and they don’t want to take a risk,” Fernandez explains while adding that she can’t say for sure how much of this fear influences their decision to recommend a surgery.
She adds that majority of the obstetricians have a solo practice and don’t have a team monitoring the pregnant woman 24x7. The only obstetrician working in such a set-up will suffer a burn out. “I will be scared that at 2 am I will have to perform a C-section when the rest of the staff will have gone home. I’d rather schedule it for 5 pm when I would have the support of the nurse and the anaesthesiologist, for example,” she adds, explaining the challenges facing such doctors in her field.
Currently though the expectant parents rely on doctors to help make the right choice for them.
Lack of enthusiastic consent
Sukruthi began to have doubts when the medical team gave her tablets meant to induce labour. She was told to not move or walk around. "The doctor told me to not make a fuss and get a C-section done as many women prefer this over natural birth and it's not going to be painful."
She and her husband, first-time parents, were both worried and frustrated. They say that no one explained to them the pros and cons of the procedure. It was not a choice - no alternative was presented to them.
A day later, even as they continued to resist a C-section, the hospital staff told the couple that their baby’s heart rate was dropping. They signed the no-objection certificate presented to them and within minutes, Sukruthi was wheeled into the operation theatre. “My doctor walked in, performed the surgery, and left. Her juniors sewed me up,” Sukruthi recalls.
Within two hours, shaking her grogginess away, she insisted that she be allowed to breastfeed only to discover that the baby had already been fed formula milk.
Sukruthi and her baby
The UNICEF recommends that breastfeeding be initiated in the first hour of birth. The mother secretes a yellow liquid called colostrum during that time which acts as a vaccination shot for the baby against infections early on in their life. Formula milk, it does not recommend.
In its latest report called Every Child Alive UNICEF points out that often even in large birth facilities health practitioners fail to make breastfeeding a priority. Moreover, C-section means the mothers would need a longer recovery time and evidence shows that i tnegatively affects her mother’s ability to breastfeed.
Making birthing happy again
It is unpleasant birth experiences such as the one Sukruthi went through that Birthvillage in Cochin, India’s first freestanding midwifery lead birthing centre, hopes to avoid. They aim to humanize the experience of giving birth. “The woman and her baby’s well-being are the focus and not the care provider or the equipment,” says Priyanka Idicula who is the co-Founder and Director. The centre claims that 96% of their birth occurs naturally. “Midwifery has a long tradition of placing the birthing woman in the centre with all the control in the woman’s hands,” Idicula says.
The loss of control over her pregnancy saw Sukruthi plunge into post-partum depression soon after giving birth to her 2.8 kg healthy baby girl, Yaanvi, now 20-months-old.
Sukruthi was angry at her doctor. “It was as if someone had broken my trust,” she says explaining that she was willing to wait and go through the pain of a natural birth.
Soon, she reached out to the Bangalore Birth Network (BBN), a network that supports individuals through pregnancy and the birth experience. Women – both from rural and urban areas – often contact the organization after traumatic experiences. In some rural hospitals the women have had their hands tied or been gagged for making too much noise during labour. While they are not given a choice ahead of a C-section, the debt after one can be crushing especially those from poor households.
“As a system, we don’t promote respectful care or prioritize the mother’s emotional well-being,” Asha Kilaru, public health researcher at BBN, talking about the healthcare system. She’s had poor women tell her that they’d prefer to die than live with the debt. Some women in rural areas are referred to different hospitals three to five times in the middle of a labour. This is mainly due to poor capacity of the hospitals in these areas that struggle to cope up when women develop complications. “What we need is for women to be given respectful and informed care that is based on evidence,” Kilaru sums it up.
Disha Shetty is a freelance science journalist. Her work has appeared in Vice, Scroll, The Wire and DNA among others.