Impatience and intolerance among pregnant women also adding to cesarean delivery

Dr. Rajiv Mahindru is Professor and Head, Department of Obst and Gynae, BPS Government Medical College for Women, Sonepat, India. He shares his experiences on how sometimes pregnant women and their relatives compel the doctors to perform cesarean deliveries to avoid labor pain while sometimes the in-laws are impatient to get the baby out as soon as possible without much caring for the health of the 'To Be Mothers'.

Pregnancy and labor are normal processes, which occur safely in majority of the cases but in cases where normal delivery is not possible or there is a risk to the baby and/or the mother, a surgical procedure is used to deliver the baby through an incision on the abdomen and uterus. This surgical process is called the Cesarean section.

Cesarean deliveries can be life-savior in critical cases but can also result in economic, psychological and physiological consequences to the expectant mother and her family. The World Health Organisation (WHO) has recommended an average of 10-15 percent of births could be cesarean section for optimal maternal and fetal outcomes, yet the rates have surpassed the recommendation in many countries.

Risks of C-section

Despite the risks that can even be life-threatening for the mother and child in extreme cases, cesarean rates are increasing. For instance, cesarean rates are 55.5 percent in Brazil, 30 percent in the US, over 26 percent in the UK. There are many complications and risks associated with a caesarean section which include (but are not limited to):

• Likelihood of requiring a blood transfusion
• Thromboembolic disease
• Neonatal respiratory distress
• Anaesthesia complications
• Risk of asthma and obesity in children
• Organ injury and infection
• Complications in subsequent pregnancies

Factors influencing increase in cesarean sections

The most common medical causes for C-section include routine repeat caesareans, large or premature babies, late age of conception, in-vitro fertilization, prematurity, fetal distress, breech presentation, non-progressive labor.

Apart from the medical factors, many other factors like socioeconomic status of the expectant mother and family, astrology, impatience of expectant mothers and relatives to bear long hours of the normal delivery process, growing intolerance among expectant mothers due to modern lifestyle, institutional factors are also responsible for increasing C-sections.

In many cases, expectant mothers or the family members themselves request a C-section delivery due to a variety of reasons like:

• Fear of pain, especially in cases of normal deliveries in friends and family.
• Pressure of litigation on in-laws from expectant mother's parental family as any unfortunate incident is sometimes blamed as deliberate negligence and conspiracy. If the expectant mother faces any untoward incident, the in-laws are blamed and sometimes police complaint is lodged for deliberate negligence. 
• Expectant mother or her family requesting a particular time of delivery, mostly due to auspicious time suggested by astrologists.  
• Refusing for TOLAC (Trial of labor after cesarean) due to fear indicted by social peers. 

In many guidelines issued to doctors across the world, it is advised that if the expectant mother is certain that caesarean section is the right option for her, then the choice should be fully respected. And that’s how Caesarean Delivery on Maternal Request (CDMR) also becomes a major reason for increasing C-sections.

Private hospitals with high cesarean section rates are also in significant demand in India largely due to CDMR.

Profiteering is not the sole reason for increasing C-sections and it is also evident by the fact that such deliveries are also increasing in healthcare facilities that are publicly funded. 

Measures to reduce cesarean rates

Considering the risks associated with C-section deliveries, it is always advised that such deliveries should only be conducted under medical indications and efforts should be made to reduce unnecessary C-sections. There is a need for a multi-pronged approach to address the alarming rise in cesarean deliveries throughout the world. 

• Sensitization

There is an urgent need for multi-level sensitization of healthcare professionals, relatives, and society at large about short term and long term complications of cesarean delivery. Misconceptions about medical indications of the requirement of C-section should be cleared. For example, previous LSCS and cord around neck cases do not always require a C-section. All Breech presentations are also not indicative of Caesarean delivery. 

• Routine/regular antenatal check-ups

Regular antenatal check-ups of the expectant mother also help in reducing the chances of cesarean deliveries. It should be kept in mind that getting an ultrasound should not be the only criteria for an expectant mother to be visiting the doctor as a requirement for ultrasound might not arise for multiple months in some cases. This will allow diligent and meticulous monitoring of the expectant mother.

• Timely referral

Facilities not equipped to handle a complicated delivery should timely refer the case to a bigger set up so that the doctors at referred hospital get sufficient time to understand the case and the expectant mother can also cope up with the situation. 

• All cesarean sections should be performed with a documented valid indication. 
• Field workers, referral hospitals and relatives should not feed the idea of cesarean delivery to the expectant mother or the doctor. 
• CDMR should be for a worthwhile reason. 
• To introduce transparency

Hospitals should be required to make the C-section rates public so that expectant mothers and their families could make informed decisions.

With all that said, it should always be kept in mind that cesarean deliveries can be a life-savior in critical cases and therefore, health facilities should never strive to achieve a specific rate, but ensure that cesarean sections are provided only to the 'To Be Mothers' in need.  

Note: Dr. Rajiv Mahindru, Dr. Swati and Dr. Dipika. Dr.  Rajiv Manidru is Professor and Head, Department of Obst and Gynae, BPS Government Medical College for Women, Sonepat, India. Dr. Swati and Dr. Dipika are residents in the department. 

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