The rate of caesarean deliveries (C-section) in Telangana, which had once gained notoriety for exploiting patients by indiscriminately performing the surgical procedure, has come down by up to 5.44% over the past year, data shows. While the rate of C-section deliveries stood at 62.53% in August 2021, it was reduced to 56.86% as of July this year. The development comes in the wake of a slew of measures introduced six months ago by Health Minister T Harish Rao.
According to the National Family and Health Survey report for the year 2019-21, more than 75% of the population had given birth through C-section in many districts of the state. The situation was so bad that in one district – Karimnagar – the rate of C-section deliveries was almost 95%, which reflected the wide prevalence of pregnant women preferring births based on astrology and private hospitals exploiting patients. Across the state, 62% of the births were done through C-section, the survey said.
As per the Telangana government’s new proposal, the health staff including ASHA workers are being incentivised to promote normal deliveries. The government is also providing Rs 3,000 ‘team-based incentive’ to the staff of the government hospital that exceeds the benchmark of normal deliveries. The optimum level of normal deliveries as per the World Health Organisation is about 85%.
An incentive of Rs 1,000 per delivery would be paid to the gynaecologist or the medical officer, Rs 1,000 to midwife staff nurse/auxiliary nursing midwifery (ANM), and Rs 500 to the ayah. The ANM working in a sub-centre and the ASHA worker who identifies pregnant women in their jurisdiction would be provided with Rs 250 each.
In addition, the government has also started monitoring births in private hospitals. It has launched an e-birth portal, through which each private hospital has to enter key details of the delivery in the portal, mentioning the details for C-section deliveries. This data would be reviewed by the Health Department to determine if the hospital had performed unnecessary c-section surgery. Recently, the government identified that out of 80 private hospitals in Nizamabad district, 54 had carried out a high number of unnecessary caesarean surgeries. These hospitals were given a show-cause notice and reprimanded by the district authorities.
As per the new programme, ASHA workers identify pregnant women in their area and take them for regular checkups to the Community Health Centres. During this period, the doctors categorise the patients under the high-risk or low-risk category based on their health status. If the patient falls under the high-risk category, which would be determined by their height and other factors, they would anticipate that the delivery would not be normal. Meanwhile, the ASHA workers would also counsel the patient to avail government services for their pregnancy, and advise against falling prey to the superstitious ideas of birth based on ‘good muhurtham’.
Based on the condition of the patient, they would be referred to hospitals — primary, community or tertiary centres. If the health team involved throughout the process of pregnancy convinces the patient to undergo normal delivery, provided the possibility of it, the team would earn Rs 3,000 as an incentive. “The patients who are classified under high-risk are asked to get admitted in tertiary centres, which are equipped with better facilities,” said Commissioner of Health and Family Welfare Shwetha Mohanty. It is the gynaecologist who will decide if a birth would be normal or C-section. In rare cases, a second opinion is considered, a district medical officer said.
To avoid tragedies, experts suggest that the government should initiate a protocol where two doctors review the case and give their opinion on whether the patient is capable of giving birth normally or a C-section is required. “Taking two expert opinions minimises the risk,” said Dr Sheela Stephen, a doctor based in Bengaluru who runs Divine Hospital.
Some argue that the government should also revoke the concept of incentives. “Provide better salaries to the staff instead. Creating awareness should be the priority, instead of forcing people to go for normal deliveries. While the efforts to prevent the menace of indiscriminate c-section surgeries are appreciable, some corrections are definitely required, and the process should be streamlined,” said Dr K Mahesh Kumar, president of Healthcare Reforms Doctors Association.
In fact, the recent death of a 21-year-old pregnant woman, Akhila, at the Nalgonda Government Hospital, had led to the allegation that the doctors were forcing patients to undergo normal deliveries against C-section to achieve their target and earn incentives. The government has initiated an inquiry into the incident to verify the truth behind the allegation. The report is yet to be sent to the office of Commissioner of Health and Family Welfare. The tragic death has drawn focus on whether the steps adopted by the Telangana government are flawless, and if the government should be incentivising health workers for ensuring normal deliveries.
“[Akhila] was suffering from dengue. She was not hospitalised for delivery. She was suffering from fever and her platelets had dropped. She had gone to the Warangal district hospital initially, and when the hospital staff asked her to get admitted, she declined. The next day, she went to the Nakrekal Community Health Centre, before finally being admitted at the Nalgonda Hospital,” said Dr Kondal Rao, District Medical and Health Officer (DMHO), Nalgonda.
According to the DMHO, Akhila’s labour pains had started while she was being treated for dengue, and she suffered excessive bleeding during the delivery due to the viral fever. “Besides, the complication was that her blood group was B-negative, which is rare,” the DMHO said. However, authorities are still looking into why a C-section surgery was not preferred when Akhila already had complications because of dengue.