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Survey: Do All Women React to C-Section Births the Same Way?

Survey: Do All Women React to C-Section Births the Same Way?

“Birth is not only about making babies. Birth is about making mothers – strong, competent, capable mothers who trust themselves and know their inner strength”

~ Barbara Katz Rothman, professor of sociology, whose work involves medical sociology

C-section or more popularly, caesarean deliveries increase year after year. Though this major abdominal surgery proves to be life-saving for the infant as well as the mother, it involves risks. Data from the National Family and Health Survey has shown that there is a significant increase in the rate of caesarean births in India.

While the World Health Organisation (WHO) recommends the rate of caesarean delivery to be 10-15%, the number was 17.2% for India during the period between January 2015 and December 2016. If this trend continues, India would have the largest number of c-section births in the world.

The article published in Hindu on April 6, 2019, authored by Aswathy Pacha under the title ‘India might soon have the most caesarean births’ said, “There is increased c-section delivery among non-risk pregnancies in the privileged classes.”

Though this statement has not been supported by any specific survey it was presumed that “several factors may be at play such as desire for comfort, and fear of pain and health risks from women and organisational and medical simplicity as well as financial benefits from clinics” behind such c-sections.

Another article titled ‘Caesarean births in India are skyrocketing- and there is reason to be worried’ in Quartz India, written by Ankita Rao on January 15, 2015, said, “According to the data of the ICMR School of Public Health, c-section births have escalated to 58% in Tamil Nadu.” It further said, “But the decision is not in the hands of the physician.”

Women who want to deliver on auspicious dates and those who want to avoid pain during deliveries opt for caesarean deliveries. Women are three times more likely to die during caesarean delivery than a normal birth.

According to another study, women encounter risks such as blood clots, infections and complications from anaesthesia during a c-section. Once a woman has had a c-section delivery, she is more likely to have c-sections in her subsequent deliveries. She may be at greater risk of future complications in pregnancy such as placental abnormalities and uterine rupture. When the uterus tears along with the scar line from the previous c-section, the risk of placenta problems continue to increase with every c-section a woman undergoes.

Pregnant women holding their prescription papers wait to be examined at a government-run hospital in Agartala March 17, 2015. Photo: Reuters/Jayanta Dey

A woman who has a c-section has to stay in the hospital for longer compared to a woman who has had a normal delivery. Caesarean deliveries increase a woman’s chances of having more physical complaints following the delivery such as pain from infection at the site of the incision, longer-term soreness, increased risk of blood loss and a greater risk of infection. The bowel or bladder can be injured during the operation or a blood clot may form.

The mother is less likely to begin breastfeeding immediately after delivery as the recovery period is longer and she may have more pain and discomfort in her abdomen and the skin and nerves surrounding the surgical scar need time to heal at least two months. Further, there are possibilities that the newborns might develop transient tachypnea – abnormal fast breathing in the initial few days, and nicks to the skin during surgery.

Also read: Are Indian Mothers Happy?

The above studies show that c-sections are common among the privileged classes and are not always the decision of the physician. Considering the risks involved for the mother and the newborn, it is necessary to limit the c-section deliveries to emergencies and as a life-saving alternative.

What is common amongst privileged women, however, need not be prevalent amongst middle-class women and women from rural areas. Even if the rate of c-section is higher among them, the derivatives can be different. As maternal mortality is higher among the lower-income groups in India, it was considered necessary to conduct a survey.

Though the government of Tamil Nadu has successfully reduced the maternal mortality rate to 66 (for one lakh births) when compared to the national average of 130, it is still higher than that of China (18.3). Additionally, the occurrence of maternal mortality is higher among the underprivileged and disadvantaged groups.

Government facilities for childbirth are over-crowded and understaffed when it comes to extending proper antenatal care to poor women who are often not well informed of medical birth practices. As a result, the decision-making power of pregnant women over their bodies is left to the doctors and the medical staff.

Photo: Reuters

The objectives of the survey are threefold: first is to find out the percentage of c-section births over natural births; second is to know under what circumstances the choice has been made by the physician or the mother to go for a c-section; and thirdly to examine the possibilities of reduction in c-sections and encourage natural deliveries amongst rural women.

With the above objectives, ‘The Forum for Indian Women Intellect’ (FIWI) which has a membership of about fifty scholarly women decided to conduct a random survey in a village on the clinical outcomes as well as the lived-experiences of normal childbirth versus caesarean births. The questionnaire was prepared to cover both antenatal and postnatal care, their knowledge on hospital deliveries and whether they had decision making power with regard to the deliveries. The survey intended to cover as many young mothers as possible in the village who had delivered a child during the last six years.

The survey was conducted in two stages. There was a preliminary visit to the village Thandarai in question and to the Public Health Centre (PHC), Thirukalukundram during February 2019 and the actual survey was conducted on June 29, 2019, by 10 women including the writers of this report. Thandarai, a village which is seven kilometres away from Thirukalukundram primary health centre and 13 kilometres from Chengalpattu government hospital was selected as the area of study.

Also read: Why Institutional Delivery in India Is a Nightmare for Women

Thandarai has two hamlets namely, Adhikesavapuram and Kuppathukundru and the survey also covered a few mothers from Amirtham Pallam which is adjacent to the Thandarai village. Thandarai village has a population of 1299 with 636 males and 663 females. According to the 2011 census, the village has registered 13.4% increase in general caste population and 0% growth in the population of Scheduled Caste and Scheduled Tribes. There are 443 people (34%) belonging to Scheduled Caste and 79 people (6%) belonging to the Irular community.

The working population is 56% and out of them 63% are male workers and 39% are female workers. The population of children under the age of six is 12% and the literacy rate is 84% among men and 66% among women. Thandarai village was chosen as the group was already familiar with the village. Lakshmi, a social worker and a midwife at the nearby SRM hospital is a connecting link to the organisation who has been engaged in a prolonged struggle to get house site pattas for the houseless families in Thandarai village.

Fifteen members of FIWI (Forum for Indian Women Intellect) were involved in fieldwork namely filling up the questionnaires, arranging a meeting of women in Thandarai village and organising a discussion with the medical staff at Thirukalukundram primary health centre. The task was not easy as most of the interviewees were busy at work in the morning at the village tank under the NREGA scheme and it was tedious for them to answer nearly forty questions at that time patiently.

The breastfeeding mothers brought their babies to the dry thorny tank beds and there was no roof to cover their heads from the burning sun. Some young mothers enjoyed the maternity break at home and some of them had undergone c-section recently and in some cases, the babies were even under three months.

After a small briefing about the nature and purpose of the survey to the investigator as well as the interviewees and on June 29, 2019, the survey was completed with all the available 40 women. The outcome of the survey was compiled and analysed.

The main findings are given below:

TABLE  1
Incidence of total deliveries, normal and caesarean section
Total C-Section Percentage Normal Percentage
40 16 40% 24 60%

 

TABLE  2
Distribution of cases according to caste
Number Percentage Number Percentage
C-section 16 normal 24
Caste BC 5 31.25% BC 11 45.8%
MBC 2 12.5% MBC 3 12.5%
SC 6 37.5% SC 6 25%
ST 3 18.75% ST 4 16.7%

Out of 40 women, 24 women had normal deliveries and 16 of them had undergone c-sections. This turns out to be 40% c-sections of the total deliveries among the interviewees.

  • While out of the 40 mothers, 52.5% belonged to the backward and most backward class communities, 30% belong to schedule caste communities and 17.5% of them belong to scheduled tribes.
  • The percentage of caesarean births is as high as 56% among SC/ST communities (nine out of 16 caesarean deliveries).
TABLE  3
Distribution of c-section cases according to age during first delivery
20 years Percentage 21-25 years Percentage 26-35 years Percentage
4 25% 8 50% 4 25%
  • As many as 75% of mothers were below 25 years when they delivered their first babies through a c-section.
  • All the mothers who had undergone c-sections are daily wage-labourers whose household income does not exceed Rs 10,000 per month.
TABLE  4
Incidence of c-sections during first and second deliveries
Total number of C-section mothers First delivery mothers only Only for second delivery mothers Mothers twice delivered
16 6

(37.5%)

1

(6.25%)

9

(56.25%)

  • Amongst the mothers who had c-section deliveries, 56.2% had twice undergone c-sections, whereas 37.5% of them had their first c-section and were likely to go for the second c-section while 6.25% had only one c-section and not likely to go for another.
  • There was a single case of c-section for the second child while the first delivery was normal.
  • For all practical purposes, we may arrive at a conclusion that 94% of the surveyed c-section mothers would fall under the category of mothers who had already undergone twice the c-section and likely to undergo c-section.
  • According to the interviewees, each had a different pressing reason for undergoing c-section and they were not aware of those problems sufficiently earlier. They further stated that the physicians who examined them before their deliveries gave the patients the following reasons for a c-section:

(i) prolonged labour pain
(ii) pelvis was too small to deliver the baby vaginally (cephalopelvic disproportion)
(iii) the baby’s head was too large
(iv) low water (amniotic fluid)
(v)  breathlessness
(vi) enlarged uterus (uterine fibroids)
(vii) baby’s head not turned (Infant torticollis)
(viii) baby’s motion bleeding
(ix) gestational diabetes
(x) baby not growing inside the womb at normal rate (Intrauterine Growth restriction)
(xi) beyond estimated due date of delivery
(xii) rectal bleeding and diarrhoea
(xiii) physical weakness

TABLE  5
Distribution of cases according to education and caste
Caste Type of birth  Level of education
Illiterate % School-dropouts % High School % Hr. Sec. School % Diploma College % Total %
BC/MBC Normal 0 0% 3 12.5% 8 33.3% 2 8.3% 1 4.2% 14 58.3% 22 (21) 52.5%
C-section 0 0% 1 6.3% 4 25% 1 6.3% 1 12.5% 7 43.8%*
SC Normal 1 4.2% 2 8.3% 2 8.3% 1 4.2% 0 0% 6 25% 14 (12) 30%
C-section 1 6.3% 2 12.5% 0 0% 2 12.5% 1 6.3% 6 37.5%
ST Normal 2 8.3% 1 4.2% 1 4.2% 0 0% 0 0% 4 16.7% 8 (7) 17.5%
C-section 1 6.3% 1 6.3% 1 6.3% 0 0% 0 0% 3 18.8%*

* Deviations in percentage are due to the process of rounding-up.

  • Out of the mothers who had undergone c-sections, 37.8% are either illiterates or have not completed their school education.
  • Among these mothers, 6.3% belong to most backward class and 31.5% belong to SC/ST sections.
  • Among mothers who had normal deliveries 56.7% of them have not completed their school education and 37.8% of them belong to SC/ST.
  • And it is interesting to note that none of the interviewees had a family history of c-section. According to the interviewees, there were two cases of maternal mortality and four cases of child mortality in the past in the village that we had surveyed.
  • All of them had antenatal check-ups as the sub-health centre is located nearby and they had easy access.
  • In the case of mothers who had undergone c-sections, 50% had availed the services of the ANM (midwife) at the sub-health centre and all have consulted the doctors.
  • All c-section deliveries had taken place at the suggestion of the doctors and the mothers didn’t have any awareness about c-section.
  • None of them knew the name of the doctor before or after c-section.
  • All the c-sections were done at the government hospital at Chengalpattu.
  • Out of the mothers who had undergone c-sections, 56.2% did not have their postnatal check-ups as they didn’t have any serious complications.
  • Everyone desired to have their husbands at the operation theatre.
  • All mothers had received the government benefits and the c-section deliveries were carried out at the government cost.
TABLE  6
Information for mothers on C-section ahead of operation
Total less than 2 hrs. 24 hrs. – 3 days more than 3 days
16 6 4 6
100% 37.5% 25% 37.5%
  • Regarding prior information to the mothers about c-section, 37.5% were informed just two hours before the operation and in two cases only a half-an-hour notice was given.
  • None of them were scared to deliver in a normal way and all of them were frightened to undergo a c-section.
  • All c-section mothers spent an average of eight days at the hospital. There was a delay in breastfeeding as mothers had to recover from anaesthesia. But as soon as they gained consciousness the babies were brought to them for breastfeeding without any delay.
TABLE  7
Information for C-section mothers about family planning operations
Total was informed was not informed
16 9 7
100% 56.25% 43.75%
  • All the mothers were operated upon for family planning. Only in the case of 43.75% mothers, the family planning operations were carried out with their knowledge. All of them reported that they had received the cash benefits of family planning.
TABLE  8
Incidence of physical and verbal abuse in the hospital for C-section deliverers
Number of C-sections Verbal abuse Physical abuse
Yes No Yes No
16 7 9 1 15
43.75% 56.25% 6.25% 93.75%
by medical professionals by doctors by medical professionals by doctors
4 3 0 1
57.1% 42.9% 0% 100%
  • Regarding physical and verbal abuse, 43.75% of mothers, who had given birth through c-section, reported verbal abuse by all types of medical professionals including doctors. 6.25% of mothers reported physical violence and verbal abuse by doctors. Among mothers who had normal deliveries, 20.8% of mothers reported verbal abuse.
  • Out of the mothers who had undergone c-section operations, 93.7% had developed consistent back pain and there was a single case of infection and another case of breathlessness.
  • All mothers reported nutritious intake of food as per the advice of the doctors or medical professionals during the pregnancy and after the delivery. None of them supported the idea of caesarean deliveries and they didn’t see any benefits whatsoever.

The findings of the random survey above reveal the following facts:

  1. In contrast to urban privileged women, rural women prefer to have regular deliveries and they are against c-sections. It is the doctors and not the mothers who exercised the option of caesarean operation.
  2. When there was no family history of c-section operations at all in their families in the recent past, the percentage of caesarean births was alarmingly high.
  3. Illiteracy and economic backwardness among women could be attributed as the main reasons driving doctors’ decisions in favour of caesarean operations rather than the medical conditions of the mothers.
  4. According to doctors, caesarean section is normally justified under certain situations such as dystocia, cephalopelvic disproportion, placenta previa, breech presentation, foetal distress, multiple births, previous caesarean section, pre-eclampsia/eclampsia, active genital herpes of mother etc. However, even when there is no pregnancy or delivery-related complication, some doctors perform c-sections as they are less time consuming and more profitable. There seems to be no record available with the patients of any of these complaints in the case of the rural women who had to undergo caesarean. The utility of government hospitals mostly by low-income groups seems to be grossly exploited by the team of doctors at government hospitals. Our study shows that the decision to perform a caesarean was undertaken by the doctors themselves, without adequate medical proof to go for a caesarean section. Although mothers were orally told about the delivery complications by doctors, it is shocking that nearly 50% of rural women are subjected to c-sections, especially when there was no family history of c-sections and maternal and child mortality in recent years.
  5. The mode of C-sections is different between rural and urban women. Most urban women opt for an elective caesarean from private hospitals, for various reasons like safety, financial viability, to avoid pain etc; but for the rural women, there is no elective or emergency caesarean. Caesarean has turned out to be a doctor’s routine with whoever is admitted to government hospitals.
  6. An increase in the rates of caesarean section delivery is a burden on the health system. Unnecessary caesarean deliveries also put a strain on the family and may complicate maternal and child health. Therefore, the decision to perform a c-section delivery must be chosen carefully and should neither be profit-oriented nor be undertaken according to the convenience of the medical doctors.
  7. Once the doctors decide the course of first delivery to be a caesarean, there is no escape from the next caesarean. This was later confirmed by the doctors during an informal discussion. They further said, as a policy young doctors are compulsorily posted in the rural areas and they are unable to cope up with the large number of deliveries every day with the meagre staff and as well as the pressure from the patients’ families.
  8. Since any maternal or child mortality at the hospital is attributed to the inefficiency of the doctors, the doctors tend to encourage safe deliveries rather than normal deliveries. While the doctors didn’t justify the increasing number of caesarean births, they defended themselves by cleverly arguing that their decisions were meant to safeguard patients from unexpected mishaps and blamed the government instead.
  9. Further, as the government fixes targets for family planning operations and the use of contraceptives for spacing between the first and second child to each government facility the doctors find it convenient to suggest caesarean operations.
  10. Though signatures from mothers were obtained during their vulnerable hospital stays, mothers’ consent regarding the use of contraceptives and family planning operations is not considered necessary as they are in a hurry to achieve their family planning targets.
  11. No discussion or dialogue between the mother and medical professionals is envisaged. It raises suspicions over whether the ruthless family planning drive of the state targets the economically, socially and educationally vulnerable women for caesarean operations.
  12. Poor mothers in rural areas return to hard manual work to make a living soon after their deliveries whether they were caesarean or normal. With the incessant back pain, women find it difficult to put in physical labour. Additionally, Dalit and tribal women are even more vulnerable to caesarean deliveries. The 56% of caesarean births amongst them exceeds the county’s average of 17.5%.
  13. As one notices the 18% gap between the male and female literacy rates in the district of Kanchipuram as per the 2011 census, there is a further gap of nearly 20% between SC/ST and other women in the village as per the survey.
  14. The facts from the random survey show serious discrepancies in the management of government hospitals with regard to maternity care. A short notice to the mothers on the major surgery leaves no room for decision making for mothers and their families. This can very well be avoided had the PHC medical professional paid attention during antenatal check-ups.
  15. Experienced doctors who have track records of normal deliveries may be encouraged and rewarded suitably by the state government.
  16. Prior counselling for mothers and their families must be prescribed in cases of exigencies leading to caesarean.
  17. Adequate video and digitally recorded proof or caesarean operations need to be maintained in support of caesarean operations. The nervousness of young doctors and succumbing to outside pressure cannot be justified for suggesting a major abdominal surgery such as c-section.
  18. The awareness regarding the advantages of normal deliveries and the rights of maternal mothers should be ensured.
  19. The persisting image of hospital deliveries as indirect family planning drives should be removed from the minds of the doctors. Encouraging vasectomies can be a healthy and fair deal for women. Allowing the required time for willing mothers to undergo family planning operation after the delivery taking into consideration the mother’s health and that of the newborn baby would be a safer practice even though it may be convenient for the doctors and mothers to have both the delivery and the family planning operations simultaneously.
  20. Due to hospital deliveries the local and traditional childbirth knowledge-base has dwindled.
  21. The dais (traditional midwife) is no longer available in the villages. Effort must be taken to preserve the best practices of traditional deliveries and they should be encouraged as part of the knowledge system in antenatal and postnatal care and in normal delivery.

P. Sivakami is a former IAS officer, Dalit activist and writer and Pearly Walter has done her Ph.D in theology from Hamburg Germany.

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