Representative photo: Isaac Quesada/Unsplash.
Giving birth is a physiological process. Humans are at the terminal end of over 170 million years of mammalian evolution that has perfected the process of giving birth to live offspring. The baby enters the world through the vaginal passage. In obstetric parlance, this is called a ‘normal’ delivery, and it confers several benefits to the baby and the mother both.
Interfering with this process is fraught with downsides. However, for a variety of medical reasons relating to the foetus or the mother, a normal delivery is not always feasible. In such cases, the baby is extracted from the uterus using a surgical procedure called a caesarean section. This procedure has become safer under modern conditions, but that doesn’t mean it is risk-free. In fact, a caesarean section increases the morbidity and mortality risk in the mother 4-5-fold relative to a normal delivery.
Despite the benefits of a vaginal delivery, caesarean section rates are rising in many countries, and not in a way that is explained by medical factors alone. The data indicates that among patients who have medical insurance, caesarean rates are performed in 60% of all deliveries (this information is from a proprietary source available to one of the authors). But in public hospitals, where treatment is free, the caesarean section rate is a much lower 20%. One way to explain this disparity is that the ‘excess’ caesarean sections may not be medically justified.
At the premier Christian Medical College, Vellore, the rate is even lower, at around 15%. According to the WHO, the caesarean section rate in a given population is expected to be 10-15% if the guidelines for prescribing a caesarean section are strictly followed.
The higher rates could be driven by considerations extraneous to the baby’s or the mother’s health. One of them is economic: Obstetricians are busy doctors and place a high premium on their time. A planned caesarean section takes around 30 minutes and can be scheduled at a convenient time. Normal vaginal delivery can take an indeterminate number of hours and can’t be scheduled beforehand. A caesarean section could also earn a hospital up to 50% more than a normal delivery.
Add to this the anecdotal preference among many patients – especially of the insured class – to avoid pain. Some may also like to schedule the delivery for an auspicious time. Such factors come together to render a caesarean section more desirable. However, this calculus sidelines the medical needs of the mother and the baby.
We wouldn’t have a problem if normal vaginal deliveries and caesarean sections resulted in similar clinical outcomes. But this isn’t the case. Apart from the risk of an invasive surgical procedure due to the risk of excess bleeding, infection, and complications due to anaesthesia, there are also longer-term consequences. For the mother, a caesarean section increases the risk of complications in subsequent deliveries. For the baby, there is a well-documented increase in the risk of childhood obesity and, to a lesser extent, asthma.
Earlier this year, a study published in the Journal of the American Medical Association showed a 46% higher risk of type 2 diabetes among women born of caesarean deliveries. Since type 2 diabetes itself increases the chance of having a caesarean section in a mother, the study’s results indicate a sort of positive feedback loop that increases the need for caesarean sections with every subsequent generation of mothers.
The authors of this study suggest one possible mechanism of action. When the baby is born via the vaginal route, it is exposed to bacteria in the birth canal. These bacteria colonise the baby’s gut and may help regulate fat and glucose. The guts of babies born through caesarean sections are colonised by a less diverse population of environmental bacteria, which may not offer the same set or extent of benefits.
Data available for the US shows that caesarean rates have increased from 4.5% in 1965 to 32.2% in 2014. The corresponding prevalence of diabetes was lower than 2%; by 2014, it had increased to a little over 7%. With each generation of women, there will be a lag of 30-40 years between the time that they are born in a caesarean section and their diagnosis as diabetics. So the increased rate of caesareans in the 1990s is still to play itself out. And even if we stopped performing caesarean sections today, it could be another 30-40 years before we might see a change in the incidence of diabetes.
The link between diabetes and caesarean births calls for an urgent response at several levels. For starters, there should be a national mandate requiring hospitals to report their caesarean rates – coupled with a mandate for obstetricians to follow evidence-based guidelines to determine the need for a caesarean section.
Second, economic incentives that drive hospitals to prefer caesarean sections must be neutralised – for example by equalising the income from caesarean sections and normal deliveries. The government should also consider reintroducing trained midwives to support obstetricians while attending to protracted ‘normal’ deliveries.
The mother and her family must also retain their agency in the decision-making process. Many mothers prefer a caesarean section because they are afraid of the pain they have to endure during labour. However, fear alone shouldn’t guide decision-making. They have to be counselled about the risks and benefits of their choice. This in turn will require a fully and formally documented informed consent process, using standardised educational materials.
The rising number of caesarean sections is ultimately a symptom of a wider problem. Wasteful and harmful medical choices driven by reasons other than patient considerations are generally common with costly procedures. In the US (for which the data is available), 50% of interventional procedures for coronary artery disease were found to be unnecessary or of uncertain benefit. Such unnecessary care diverts economic resources that could be applied to delivering healthcare for the poor.
Indeed, in the US, wasteful healthcare is believed to account for 25% of total healthcare costs. Using a similar estimate for India would imply the savings would be around Rs 2,000 crore – with attendant benefits for health outcomes as well as the healthcare economy. A national body of experts constituted to include representatives from healthcare and insurance companies must be charged with examining this issue and implementing corrective measures. This can’t be delayed without jeopardising the health and economy of the country itself.
Swami Subramaniam is the author of Healing Hands, a hand surgeon’s biography. Aparajithan Srivathsan is the managing director of Intent Health Technologies. They are joint authors of the book Hospital 5.0, to be published in 2021.