Tuesday, February 07, 2006

Caesarean Deliveries: Scientific Progress Gone Boink

Over the past months, a few of my friends and acquaintances have delivered babies. All of them have gone to private hospitals here in Bangalore, some large, some small. Nothing out of the ordinary here, right?

Well, what is out of the ordinary is that the fact that almost all of them have delivered their babies by Caesarean Section (C-Section).

The Indian medical academic community (see p. 6 of that article) estimates that the rate of C-Sections in private hospitals in India is as high as 45%. A conversation I had with the labor and delivery department of a reputed private hospital here, however, puts that percentage at a mind-boggling 70%.

This rising trend in the use of C-Sections for delivering babies is not unique to India.

A Time magazine article (Too Posh to Push, April 19, 2004) highlighted some of the countries with higher than recommended rates of C-Sections (the World Health Organization recommends that C-Sections make up less than 15% of all births). England has a 22% C-Section rate, while Italy's had climbed from 21% more than a decade ago to 33% at the time the article was published, and Brazil takes the cake with some private clinics in that country reporting C-Section rates as high as 90%.

There are, of course, cases of maternal and fetal distress when C-Sections are warranted. And advances in technology, anasthetology and obstetrics have meant that more C-Sections have been performed in recent years in such cases, and they have resulted in more mothers and fetuses surviving childbirth.

There are a few other reasons, however, for this rising trend in the deployment of C-Sections:
  • women opt for C-Sections as a matter of convenience – they want to avoid going through long and painful labor;
  • doctors, overwhelmed with the number of patients they see, have neither the patience nor the time to allow labor to take its normal course; and
  • doctors push C-Sections (which cost twice as much as normal childbirth) on their patients because their hopitals or clinics recuperate the investments they've made in purchasing expensive machines for conducting C-Sections.
And in India, add at least a couple more reasons to that list.

According to this Hindu article, some families are opting for C-Sections because they want their baby delivered at an "auspicious" time. The normal childbirth process, of course, affords no such control over the time of birth. Secondly, some fathers-to-be are "forcing their wives to undergo caesarean section, believing that normal delivery hampers their sex life."

There are, thus, two main prongs in the list of reasons why C-Sections appear to be the preferred form of childbirth: one is the woman or her family's search for control (over pain, over time of birth, over post-delivery sex life) and the other is the doctor's search for control (over cashflow generated by deliveries and over his/her time).

While C-Sections have generally become safer over the years, doctors warn that certain risks remain. C-Sections are major surgeries and among other risks, although the mother may allay the pain for a few hours, recovery can be long and painful. This is definitely not to say that normal childbirth is a walk in the park. There are risks for both mother and child associated with prolonged labor.

Given this scenario, if you are a woman that prefers normal childbirth, what are your options?

There are quite a few steps you can take to be fully prepared before you enter the birthing room.

The first step is to educate yourself regarding the pregnancy and its various stages and the whole labor and delivery process. The internet is a veritable treasure trove of information on this topic. There are also books such as What to Expect When You're Expecting that take you through the pregnancy in an organized and methodical fashion. The third source is information is, of course, your doctor. Do not hesitate to ask questions during your visits.

In fact, talking to your doctor should be a priority. Talk to her about her thoughts on childbirth. What are the scenarios in which she would resort to a C-Section? Is her staff supportive of normal childbirth? Is the hospital equipped to take you through that process? What happens if you go into labor and she is away that day? What are the policies on letting someone (husband, mother) stay with you during labor? And educating yourself allows you to ask the right questions.

If you can find a natural childbirth class near you (most hospitals offer one these days), take it and take your husband or mother (whoever will be with you during labor) to the classes. So you have two minds thinking the day of the delivery rather than just one (labor is as much in the head as it is in the body). Practice the breathing and relaxation techniques they teach. They really do work.

Finally, establish a rapport with the doctor so you feel comfortable and can trust the doctor to do what is right in the end, because no matter how much you've prepared yourself and how much you want natural childbirth, circumstances may prevent that from happening and your doctor may decide that you will need a C-Section after all.

That brings me to the most important point of all - prepare as much as you can to have the kind of childbirth you want, but also prepare yourself to go with the flow. Because while there are many things you can control, it is also wise to acknowledge that there are many more things you cannot.

And that, from personal experience, is a recipe for smooth labor (if there is such a thing).

Note: This article is not meant to be a substitue for professional medical advice. Please consult your doctor for advice regarding your specific circumstances.

Crossposted on Desicritics.org.

57 comments:

Hilal said...
This comment has been removed by a blog administrator.
Hilal said...

I am a fan of your blog, Sujatha. Thanks for this smart, informative piece on C-Sections.

bharath said...

a very interesting blog. something i did not know know about before.

one thing i did hear from a friend: the C-sections are high in Europe and increasing, because the doctors are getting sued very heavily in case the natural labour gets into complications. so they try to 1. avoid the risk when possible and 2. high priced C-sections can recover the money lost in law suits.

so both patient and doctor benefit in a way, but the question still remains of "ethics".

Of course this is what I heard.

Sujatha said...

Thank you Hilal and welcome to my blog.:))

Bharath, I know that in the US at least, what you say is right. In fact, malpractice premiums are extremely high for OB/GYNs already. But in India, of course, that is not the case. The overriding reasons for doctors to resort to C-Sections seems to be convenience and money-making, neither of which is ethical whichever way you look at it.

Ravi said...

Truly, a well-written informative post, Sujatha! What can I say but we have 3 kids (includes a set of twins!) all of them delivered in traditional style - No C-sections! Doesn't that make my wife a super-woman? :)

Sujatha said...

Hi Ravi, thank you and absolutely! Hats off to your wife.

... said...

OMG!! People opt for C-sections keeping in mind "auspicious" times? Where are we headed? Next thing we know an "auspicious time" will be kept in mind during conception :-S

Ridiculous!

First time here. Nice post.

Sujatha said...

..., I'm glad you commented on that. That blew me away as well. And funny you should mention looking at auspicious time during conception. When I was scouring the internet to gather information for this post, I came across an astrology website that actually mentioned that it is no use looking for an auspicious time at which to deliver, but rather couples should do that when they are trying to conceive. So you were in the right track!

Charu said...

not now, honey! I have a rahu in my fifth place...
but seriously! when I tarted reading your post, I thought of the auspicious time bit and then you had mentioned it too... I have seen that doctors too - except the really old ones who scoff even if the woman suggests it - try to push for a c-sec, they do make more money that way...
in any case, it is not as if csec deliveries are entirely painless... an operation is painful enugh to recover from...

Sujatha said...

Charu, that was funny about the rahu part. And you're right about C-Sections being more painful. Everything else being normal, they're really not worth the pain (and the money).

By the way, what's going on with your blog? It takes me to Madman's page and then says the account is suspended. Hope to see you online soon.

MumbaiGirl said...

I have emailed you. But the issues you've raised here are some that have been worrying for some time. Am storing it all up for when I have children.

gawker said...

Thank you for all the information. I hope to use it soon. Any advice on making men ready for childbirth?

Sowmya said...

In India there is no concept of 'induction of labor' as opposed to the US. If labor is not progressing well they immediately do a c-section. Atleast in the US they put you on pitocin and wait the required amount of time to see if labor progresses at all and then decide on a c-section. Women also don't realise how easy(realtively speaking) it is to recover from vaginal child birth.

I have always wondered, do women that deliver via c-section 'feel as connected' to their baby like women that do it naturally?

Very informative post.

Sujatha said...

MG, thank you for your e-mail. Have replied.

These issues do bear a lot of thinking and mulling over, but of course, you should wait until you actually plan for children. Good luck with everything.:))

Gawker, you're very welcome. I do hope all this stuff is useful when the time is right.

I should tell you about men and childbirth. So many of our male friends offered to be there at the hospital if my husband happened to be out of town. It was completely weird. It was only men who'd had children themselves though. Then I realized that men just love this whole childbirth thing, being there for their wives, being part of the labor and delivery process.

Here is something I wrote for a magazine on what we went through the day our son was born. You'll get a fair indication of how my husband was (he was an absolute sweetheart).))

http://blogpourri.blogspot.com/2005/06/labor-of-love.html

That said, I would just suggest reading up as much as you can yourself and attending the childbirth classes. The book I mention (What to Expect When You're Expecting) has about 22 pages of stuff for fathers-to-be. One note of warning, though. Use that book only when you have an issue, find it in the index, read about it and then close the book. It's an awful litany of every conceivable problem pregnant couples have, that book. But it's a great reference.

Sorry about the overload. I'll stop now. I could go on and on about this. But feel free to e-mail me and I'd be glad to help in any way I can.

Sujatha said...

Sowmya, thank you for the comment. You're right about inducing labor. I took the pitocin, actually and it worked really well. Thank you for raising that. I actually don't know what hospitals do here. I haven't asked. But I have heard of operations being done even before the due date.

I've also read that C-Sections intervene with the mother-child bonding, but I think it's taking things a bit far. Even with normal delivery, you're so out of it with all the things going on around you that I think it all takes time to sink in anyway and feel like you're finally a mother. It may interfere with the feeding, though, but this is also something you can overcome if you are determined enough.

rajeshwari said...

Sujatha
Nice piece of research, hope lot of women will benefit from the info.
I also wanted to mention two things which are common in U.S epidural and episiotomy. The nurses out here love it when you take an epidural as their work is reduced.
Recovery from vaginal birth is not always fast if you had an (3rd or 4th degree)episiotomy.
check this out
http://www.changesurfer.com/Hlth/episiotomy.html

http://www.birthingnaturally.net/barp/episiotomy.html

Michael Higgins said...

Hi Sujatha
Interesting post.
If my wife were to do it all over again she would have definitely opted for C-section. She doesn't tolerate pain well and childbirth is pain like no other. She refused to have another child. I thought she might reconsider after several years but that pain was tramatic for her.
I wished we had had the option. I really wish that.

Sujatha said...

Rajeshwari, thank you for that. Epidurals are common in the US, but in most cases they end up in C-Sections because labor tends to get prolonged. You may be right about epidurals not being available here, but I think episiotomies are routinely done.

Michael, that is unfortunate. I have friends in the US who've scheduled C-Sections way in advance of onset of labor (one because she was very far away from her doctor and did not want the uncertainty of going into labor and then not reaching her doctor in time, and the other just did not want to deal with the pain). So the next time around that might be an option for you.

Just curious, did you take childbirth classes that taught pain management techniques or was taking epidural an option?

Charu said...

(just to tell you my blog's back in action:) there was some problem yesterday)

Charu said...

in response to sowmya's (and someone else too?) question about mother-baby bonding, I think c-section deliveries will not affect that in any way.. what about women who adopt children and bring them up as their own and love them s much as they would love their own "blood"?

Sujatha said...

Charu, thanks for letting me know, and that's a great point you make about the bonding.

Michael Higgins said...

Hi Sujatha
We took all of the classes and were fairly well prepared. Her labor was induced so it didn't proceed smoothly. She took the epidermal too soon and it wore off.

Btw, if you ever happen to meet my wife, you never heard any of this.

Sowmya said...

@charu, I was talking more about 'feeling connected' with the process of birthing than the actual mother-baby bonding. With anasthesia and a curtain in front of you during a c-section and the wait to see your baby after you've heard the crying, all can be unnerving and give you the feeling that its all happenning at a distance.

Sujatha said...

Michael, oh. Epidural has the nasty habit of doing that, unfortunately, although I know a lot of people who will swear by it.

And you have my word on the second part of your comment.:))

Sowmya, I see what you mean. You could end up feeling like a spectator at your own childbirth and a bit removed from the whole process.

gawker said...

Thanks again for the book tip. Looks like it's one I'm gonna have to hide from the wife since she's so paranoid.

Sujatha said...

Gawker, no problem. :)) One book about pregnancy she will enjoy reading is THe Girlfriends' Guide to Pregnancy (Or Everything the Doctor Won't Tell You) by Vicki Iovine. It's lovingly written, very, very funny and useful at the same time. I'm sure it's available on Amazon.

Anonymous said...

hi !

I spent the last 2 years of my life having babies. Baby # 1 (son) was had a normal delivery and Baby #2 (Daughter)was delivered through a c-section.

I do not feel there is any question of disconnect or not being able to experience the childbirth in case of c-section because the spinal block ( anasthesia) only numbs you waist downwards.

The pain starts only once your staples start healing and you try to walk.

At the risk of sounding a little smug , I must say the whole thing about childbirth being painful, difficult is a bit much for me to understand. Nature has engineered a woman's body perfectly for this.

Question is she prepared mentally ?

ps: sowmya indian hospitals have induction of labour, epidurals, cord banking etc etc. so go easy on the patronage

Quizman said...

Sujatha,

This is a pretty serious statement:Epidurals are common in the US, but in most cases they end up in C-Sections because labor tends to get prolonged. Do you have stats that back the statement? Because, we didn't hear about the correlation between epidurals and caesarian deliveries during the birth of our child. [I am in the US]

Childbirth.org is a good site. The Stanford Hospital site has good information too. The section on labor/epidurals is here

Btw, i didn't take the Hindu article on caesarians and "auspicious" times seriously. It must be hearsay. It is too foolish an idea and must've been made up by the journo. :-)

Quizman said...

Btw, my wife had 26-27 hours of labor. She took the epidural after 12 hours, iirc at stage 2. After about 24 hours, she was fully effaced and dilated and was made to push. She did for two hours, but to no avail. Then they tried suction, but kiddo wouldn't come out. :-) Then they opted for caesarian since his heart beat was going down whenever they tried to yank him out through suction.

So to answer to Sowmya's statement I have always wondered, do women that deliver via c-section 'feel as connected' to their baby like women that do it naturally?, the answer is a big YES.

Though, there is a correlation between breast-feeding and bonding. At Stanford, they try their level best to get the babies to breast feed for as many months as possible. It is not only good for the baby's immune system, but is also good for the mom and baby's psychological needs.

Quizman said...

Sowmya wrote:

With anasthesia and a curtain in front of you during a c-section and the wait to see your baby after you've heard the crying, all can be unnerving and give you the feeling that its all happenning at a distance.

The wait in our case was about 2 seconds. The doctor lifted the baby above the curtain and said, 'Mommy look, your baby. He's fine!" :-) Within an hour, she was holding the baby and trying to nurse him. :-)

Sujatha said...

Anon: thank you for your comment. Congratulations on your two babies.

Just as all of us are not prepared to sit in a rocket and be blasted off to space, or sign up with the army and go fight in a war, many of us are apprehensive (rightly so) of the pain (quite simply because we don't know what it is). So some women feel unprepared for the pain, the discomfort of childbirth
is perfectly understandable and they are not lesser women or human beings for it.

Quizman, thank you for your comments and for sharing your experiences. Sounds like you guys had a great attitude during childirth. Good for you. That's half the battle right there! :))

About the connection between epidural and C-Sections, "More women request an epidural, which, according to some studies, can lead to an inefficient labour then a caesarean delivery," according to this article - http://www.readersdigest.ca/mag/2001/06/caesareans.html. The percentage I had read earlier was about a third. So while most of the cases where epidural is taken may not lead to C-Sections, a percentage of them (I had read about a third, somewhere) certainly are attributable to epidural. But like I also said, I have many friends who have taken epidural and have gone on to have normal deliveries and swear by it.

About the Hindu article, as I mentioned in one of my previous comments, I did go dig around on some astrology sites and here's an example of one that encourages that sort of thing: http://www.indiamart.com/saieastrology/
and another example from a different news source: http://www.newkerala.com/news.php?action=fullnews&id=61894

And apparently, it's not just us Indians who fall prey to this idea: Take a look at this! http://fortuneangel.com/caesarianbirth.htm

Sujatha said...

Anon: About epidural, induction, cord-blood banking etc. being available in India, they are still not routinely available (the hospital in which my niece was born did not have epidurals - my sis-in-law liked her doctor very much so she decided to stick with that hospital) in the more expensive hospitals and not to a majority of the general population.

Harish N Jeyavel said...

True, this trend of Caesarean Section is not an healthy one. We were warned about this in our internship days back in 2001 and it gets only worse as this trend will only grow. The earnings for the Medical Personnel(hospital, doctors, para medical...), from C-Section is much more than a normal delivery.

Sujatha, you discuss the so called "outside medical field" implications and consequences of the practise and you have done a good job.

Here are some interesting facts, The gestation period is about 280 days or 10 months, but when it comes down to the labour, the fetus plays more role than traditionally thought, i.e, The fetus decides when she wants to come out. How is this exploited by the system? the person incharge decides a C section, for some lame excuse, the event (operation) becomes a planned exercise which can be scheduled to the convenience of the doctor, more intervention, more morbidity, more hospital stay and finally more money.
There are only a few handful indications for C section, some absolute and some relative

Apart from all this birth is a natural process.A woman need not undergo an invasive medical procedure unless it is indicated!

Sujatha said...

Jayavel, thank you for visiting my blog and adding your thoughts.

Sujatha said...

In my second to last comment, I said: "About epidural, induction, cord-blood banking etc. being available in India, they are still not routinely available ...in the more expensive hospitals and not to a majority of the general population."

Oops! That should read, of course, "they are still ONLY routinely available...in the more expensive hospitals and not to a majority of the general population."

The Marauder's Map said...

I'm glad to know I'm not the only one who thought all babies were born by C-Section these days. Out of all the people I know who have given birth over the last 3 years or so, more than ten babies in all, NOT ONE has had a normal delivery.

Anonymous said...

I know nothing about the situation in India but here in Sweden the average age of women having their first child is now 28. Add in that babies are getting bigger and bigger as well and the risk for injuries when giving birth naturally is much higher.

All of my friends except one had to have stitches after giving birth naturally. One of them was even told that she was lucky she didn't tear all the way to her anus.

These are the factors that make me positive towards a cesarian if I ever decide to have children.

Sujatha said...

Hi Shrabonti, thank you for your comment.

Anon: If that is the way you feel, that is exactly what you should do. My problem is more with doctors and hospital administration policies pushing women to have caesareans when they are not medically warranted.

Anonymous said...

Oh I see. Here you have to prove that you have a phobia for giving birth before you get one. We seem to be at different ends of the extreme.

marybethorama said...

What concerns me is also the fact that it is not impossible in many areas to have a vaginal birth after a c-section (VBAC)

My first was a c-section after labor was augmented with pitocin.

The two after were unmedicated (natural) VBACs. The second baby weighed 10lbs2oz.
The third weighed 9lb 11oz.

I did tear a bit with the third but it didn't hurt at all and it healed beatifully.

Sujatha said...

Anon: that's one way of looking at it.:)

Marybeth: Congratulations on your babies and it's amazing that you did VBACs and am happy you had good medical support for that.

the nut said...

I had an emergency c-section and was knocked totally out. There was no blue curtain or waiting to see the baby afterwards because my placenta had ruptured and there wasn't any time to wait for a local anesthetic to kick in.

So I didn't get to see my little man 'til the next morning when whatever they gave me finally wore off. I don't believe the mother-son bonding was hindered in anyway as we immediately clicked and have done just peachy ever since.

What is important to remember when talking about c-sections, is not all mommies who had one did so of her own volition. Sometimes it really was a medical necessity/emergency.

Thanks so much for posting on this, Sujatha. It's stuff like your post that I wish I would have had access to when I was pregnant. I wasn't at risk for complications at birth so I only read the chapter in What to Expect When Expecting and that's it. Afterwards, I was really wishing I had read more just in case.

Sujatha said...

Nut: thank you for your comment. That is precisely the kind of balance I wanted to bring to this debate (C-sections vs. natural childbirth). So often any discussion on this topic is so judgemental that people fail to see that both methods are perfectly ok, if that is what is necessary and that is what you (as the mother-to-be) wants to do. My main grouse is with doctors who push C-Sections for their own benefit even on women who want natural childbirth.

It's almost springtime in VA! Missing it! Loved the pic of the dogwood on your blog. Hugs to your little one from me.

Sujatha said...

Correction: ...you "want"...

Shilpa said...

I was in labor for 8 hours before the doctor found that the baby was posterior and I had a C-section. I had taken Epidural as soon as I was 4 cm dilated. I just could not bear the pain. I am one of those people who thinks that you need not try to be a hero by not taking Epidural when you have an option and I was glad I had a C-section. I will opt for a C-section for my second one. Recovery is easy. i hardly felt anything. No Episiotomy or incontinence or chances of fistula later.

Sujatha said...

Shilpa, thanks for visiting and commenting. I'm glad things worked out for you. The important thing about the childbirth process is for the mother-to-be to recognize what works for her and go for it, rather than being forced to do what others think is right.

paige said...

I am a Lamaze-trained childbirth educator and doula from the US living in Bangalore. I offer private as well as group childbirth prep classes. Topics covered include anatomy of pregnancy and birth; pregnancy exercise and nutrition; stages of labor; developing and maintaining confidence in the inherent ability to give birth; strategies to facilitate normal birth; movement and positioning which enhance progress and comfort; technology, interventions, and pain medication; cesarean births; postpartum issues; breastfeeding; and newborn appearance, needs and capabilities. For more information, contact me at nycdoula@gmail.com, or on 99863 80303.

bird's eye view said...

Hi Sujatha,

I'm new to the world of blogs and recently discovered yours which I read with great interest. I'm a kannadiga too, which adds to my level of interest.

I just read your blog about caesarians, and yes, they are increasing in frequency. Most people I know who have had kids in the last 5 years have had a C-section, including me. However, speaking on the other side, my gynaec told me this horrifying story about her assistant, whose mother-in-law was so determinedly anti C-secs that when they found the baby had the cord wrapped around his neck, the m-i-l made the assistant lie with her legs suspended in the air for three days, hoping to make the cord slip off!

In India, it's not really about C-secs or natural child birth, what is critical is that everyone involved (including in-laws or parents) be well informed about all the options and the risks.

Sujatha said...

Paige, thanks for posting that useful information, but please don't post it on too many articles. Thanks.

BEV, thanks for your comment. That is precisely my sentiment as well. What is critical is that we are involved in the medical procedures we undergo and we are aware of why something is done to us.

Anonymous said...

Sujatha, I enjoy your post!
I'm in obstetrics in the U.S. and (at the risk of overgeneralizing) in my observations, Indian women in labor are much more hypersensitive to pain than others. If they make it to fully dilated, they often do not push well, very often refusing to even try, and asking for a cesarean even though labor is progressing normally. I'd like to know your observations on this.

small squirrel said...

hey anonymous....

um... *risk* of overgeneralizing? wow. no risk there, you actually simply did overgeneralize, and quite offensively at that.

as a physician you should know that there would be absolutely NO feasible way that one race or ethnicity would be prone to being hypersensitive to pain over another.

also, uh, india has how many gadgillion babies born every year, with millions done in rural set-ups with absolutely no pain medication and very few c-sections. how do you figure that happens? I mean what with their inability to push and their refusal to try.

I assume you are in the US, where the rates of c-sections are out of control. so how about the frighteningly high rates of obstetricians goading patients into unneeded c-sections? I'd like to know your observations on THAT!

Sujatha said...

Anon, thanks for your comment, but that was an unfortunate bit of generalization there. Perhaps you are talking of sheer numbers (if your clients are predominantly Indian) rather than rates. I agree with smallsquirrel when she points to the rural population in India is lucky to get a hospital to go to for delivery, forget advanced medical services such as edpidurals. I don't know your sample composition, but among my Indian friends, I know more who've had normal, non-medicated deliveries.

Smallsquirrel, thank you for a point very well made. :)

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