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Avoiding pain at any cost
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While the West is looking at ways to drastically reduce caesarean births, Kerala, a state which has WHO-acclaimed infant mortality rate and the highest gender ratio in the country, seems to be doing the opposite, says SHWETHA E. GEORGE.
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DR. X is a gynaecologist in a private hospital in Thiruvananthapuram. The hospital does not pay him a salary. His "fee" comes from the caesarean surgeries (CS) he conducts between 1 p.m. and 5 p.m.. At the end of day, he gets approximately Rs. 40,000 — the cut deducted from patients' bills.
In a super-specialty hospital on the outskirts of Kottayam, a semi-urban town in Kerala, most mothers-to-be come asking for a "painless labour" or a CS. These women, from upper-class Syrian Christian families, are willing to take any risk as long as they can avoid pain.
Doctors, especially obstetricians, throughout Kerala are insuring themselves against professional indemnity. This is because incidences of litigation on the grounds of negligence inside the maternity ward are on the rise and Kerala, doctors claim, could soon become the State with the highest rate of litigation against them.
The reproductive health of the Malayali woman is considered far better than that of her counterparts in other parts of India but Kerala, in recent years, has been showing an appalling rate of caesareans done in super-specialty private hospitals.
While hospitals in the West are looking at drastically reducing caesarean births, the State which has a World Health Organisation (WHO)-acclaimed infant mortality rate (13 per 1,000) and the highest female to male ratio in India (1,067 females to 1,000 males according to the 2001 census), seems to be doing the opposite.
In a survey undertaken at the Achutha Menon Centre for Health Science Studies (AMC), Thiruvanthapuram, the medical records of 360 mothers admitted to various private hospitals in Kozhikode, Ernakulam and Thiruvananthapuram have shown that the rate of caesareans conducted is around 50 per cent and normal deliveries between 20 to 25 per cent.
According to WHO norms, under appropriate technologies for birth, the rate of caesareans anywhere in the world should not be more than 15 per cent. In fact, hospitals that used to have a high rate of caesarean births in the West, like the Mount Sinai Hospital in New York and others in United Kingdom and Sweden are addressing the issue by looking at only referred cases and auditing the number of caesareans done by each gynaecologist.
A caesarean is the primary cause of maternal mortality and morbidity rates. A wound infection, haemorrhage or inappropriate blood transfusion during the surgery can lead to the death of the mother. Incidence of morbidity ("state of sickness") is also high with surgery. She has to avoid strenuous work and rest for about three months. (In the case of normal labour, a mother can resume her chores after 15 days. The negligible rate of vaginal birth after caesarean in Kerala also accounts for maternal morbidity. Only one in less than 50 mothers interviewed in the survey had a vaginal birth after a caesarean, and only if it was a premature delivery.
In fact, of the 360 mothers interviewed in the three cities, 90 per cent said they did not discuss the mode of delivery with their gynaecologists. Only 15 per cent said they would have had a caeserian had they been asked their choice. Then why are caesareans rampant?
"No doctor wants to take the risk of waiting for normal labour," says Dr. Vijaya Stephen, gynaecologist who runs her own clinic in Ernakulam. First, she says, the doctor doesn't have the time for individual attention. Second, given the quality-treatment in private hospitals, the mother's and child's safety is ensured. And most important, a caesarean is ideal considering the doctor's own interest.
"Because the system has become very litigious. In the event of a problem, the family members and the public, at large, can get very nasty."
"The public have always had a mistrust towards private doctors," says Churchin Ben, deputy director (retired), State Health Department, mainly because of the money involved. Other than government and private hospitals, Kerala has a number of mission hospitals generously backed by religious denominations. The ostentatious display each time a new wing is inaugurated or equipment imported works against the favour of the non-governmental medical fraternity.
In fact, the medical fraternity, especially those in obstetrics and gynaecology, take all steps needed for a delivery free of complications. One of these is to make caesareans the order of the day.
"Even if there is a 90 per cent chance of normal delivery, we would still do a caesarean taking into account the remaining 10 per cent," says Dr. Stephen, who has taken an insurance policy of Rs.15 lakhs against professional indemnity, just like her counterparts in other private hospitals. "There are not enough doctors or trained nurses for each patient who can monitor her as labour progresses. There are no such things as foetal monitors either," says Dr. Achamma Thomas, former gynaecologist with the Government Medical College, Kottayam.
"In a private hospital, the doctor works using limited facilities. It would be suicidal for him to wait for the patient to show signs of normal labour. A caesarean is the safer option," she says.
A caesarean has other benefits too. A gynaecology department can plan the number of surgeries per day — it ensures more money in the hospital's kitty. And although the medical fraternity insists that gynaecologists do not get a "cut from the patients bill towards hospital expenses", sources in the State Health Department beg to differ.
Social factors also play a role in hiking the rate of caesareans. "Kerala has a semi-urban population," says Mr. Ben. "The level of awareness is high. Deliveries rarely happen at home. Even in a village, you will find mothers-to-be visiting a hospital regularly. Every five kilometres there is sure to be a clinic, every 10 km you will definitely find a hospital."
Says Mala Ramanathan, associate professor at the AMC and an expert on reproductive health, "It is actually a double-edged sword. Where caesareans are concerned, there is a certain amount of medical care involved. That is, taking a perfectly natural process like child-birth into the realm of medicine, and then treating it like a disease. Medical supervision of the birthing process, yes. But irrelevant medical diagnosis?"
She says one can find four to six MRI centres every 36 sq.km. in Thiruvanthapuram. You can find at least 36 ultrasound scanning centres within the same distance.
On the other hand, a doctor faces problems from families which have high expectations, not only of a safe delivery but also of an ideal post-delivery phase. The patient doesn't want too many problems that could affect her later and the family wants the child to be born on a specific date or at a specified time that has been decided by the family astrologer.
There is intervention from both sides. "Sometimes a caesarean becomes absolutely necessary when complications arise. An elective procedure says Ms. Mala, is what is uncalled for, irrespective of who takes the decision — the doctor or the patient.
In fact, the demand for a caesarean increases as one goes up the socio-economic ladder. The general attitude, apparently, is that since caesareans have become the norm, it must be normal. "But even a normal delivery is not normal in its true sense," says Dr. Hemachandran. "Artificial induction or rupturing of the membrane are methods practised even for a normal labour. An epidural shot might also ensure a few hours of painless labour for the patient but it automatically initiates instrumental delivery use of forceps."
Says gynaecologist Dr. Jaipal at the Matha Hospital, Ettumanur, "Young mothers have a wrong idea about pain. Some even feel that post-operative pain is more bearable than a normal delivery."
The emphasis, therefore, should be on ante-natal treatment where the mother-to-be gets to know the facts about her health and is advised on the mode of delivery most suitable. Upper class or not, women must not assume that just because caeserians have become the norm, it's normal.
"A doctor's primary responsibility is to discuss the pros and cons of each mode of delivery and influence the decision of the patient although the final choice is left to her," says Dr. Hemachandran.
If Kerala has been lauded repeatedly for achieving exemplary standards in the health sector, it's high time the results showed.
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