The caesarean section (C-section) versus normal delivery debate has made a comeback after Ministry of Women and Child Development wrote to Union Health Ministry to make it mandatory for hospitals to display their rate of caesarean.
The move came after a petition on change.org, which had received 1.3 lakh signatures, was submitted to Union Minister Maneka Gandhi against abnormally high rate of C-section deliveries in India.
Doctors however say it is unfair to see rise in C-section delivery rate in isolation as every pregnancy is different from other as it involves various factors.
“Looking at an individual parameter called C-section is wrong. We also need to consider the age of conception of a woman, pre-pregnancy health parameters like anaemia, body mass index, Vitamin D level among others, thyroid, diabetes and hypertension status before analysing outcome of delivery option,” said Dr Sangeeta Pikale, Gynaecologist.
She said Indian health care requires a registry for all diseases. “Registries will help us analyse health sector better as presently we rely lot on guidelines, studies, prevalence rates abroad and since Indian health parameters are different from those seen in countries like USA and UK,” said Pikale.
The Federation of Obstetric and Gynaecological Societies of India (FOGSI), an umbrella body of gynaecologists in India, is in process of having Indian guidelines for caesarean section and vaginal delivery with the help of international criteria and guidelines.
“At FOGSI, we are working on Indian guidelines for caesarean section and vaginal delivery with the help of international criteria and guidelines. The process has been initiated,” said Dr Rishma Dhillon Pai, President of FOGSI.
However, she said there are many variables like abnormal presentation such as breech or transverse lie, foetal distress, a prolonged labour, bad obstetric history, pregnancy in older woman with high blood pressure and diabetes among others, which play a role in deciding C-section as a delivery option.
“If one woman is having a normal delivery, it doesn’t mean others too will have a normal one. Only the doctor present at that moment is the best judge. In pregnancy and labour, dynamics keep changing every minute and nothing can be pre-decided,” said Pai.
In a 2015 news release, referring to new findings, the World Health Organisation (WHO) had said when caesarean section rates rise towards 10% across a population, number of maternal and newborn deaths decreases. It said it is important to ensure a caesarean section is provided to the women in need and not to just focus on achieving any specific rate.
Doctors say there is an urgent need by the government to work in improving patient-doctor relationship.
“Such statements issued by ministry will develop mistrust between patient and doctors and will results in refusal of surgery when it is a must, leading to more maternal and foetal mortality and morbidity,” said Dr KK Agarwal, National President, Indian Medical Association, an umbrella body of modern medicine practitioners.
He said rates of caesarean will always be higher in secondary and tertiary care hospitals because of referral of high risk pregnancies.
“In such hospitals, there will also be reduced rates of maternal and infant mortality. Similarly, rates of caesarean will be higher in urban scenario than the rural scenario because of better facilities and again with reduced rates of maternal and infant mortality. We should rely on national average and not a city average. One cannot rely on the results of a petition,” said Agarwal.
Before making any law government should collect statistics, which it simply does not have. Let us see what data is required to draw any conclusions w.r.t. cesarean section
1. Date of birth
2. Sex
3. Birth weight
4. Maturity
5. Mode of delivery
a. Normal
b. Forceps
c. Cesarean
6. If intervention required, reasons thereof
a. APH
b. Breech / transverse lie
c. CPD
d. Diabtets Mellitus
e. Previous LSCS
f. Fetal distress / asphyxia
g. Gestational diabetes
h. Hypertension during pregnancy
Most of this data is collected for birth certificate. If all data from all government health departments is analyzed properly, it will be easier to determine
a. Which cities / hospitals / doctors have high rate of LSCS
b. What are the reasons for which LSCS is being done
c. If the reasons are not satisfactory, what actions can be taken to reduce rate of LSCS.
Writing number of normal / LSCS on notice board will not be of any use. Is MOH&FW going to take responsibility of any mishap during delivery?
Suggestions on above most welcome. Planning to write letter to Maneka Gandhi in a couple of days.
Dr Rajeev Joshi
HOW DO U JUSTIFY 90 % C SECTION AGAINST WORLD (NOT WEST) STANDARDS OF 10-15%
श्रीमती गांधी जी द्वारा की जा रही अपील सचमुच आज की ज़रुरत है, मेरी बहन के तीन ऑपरेशन हुए और मेरी भाभी को अस्पताल में एक छोटे ऑपरेशन के लिए 15 दिन इसलिए रखा गया की उनके टांके ख़राब हो गए थे, यह सब एक ला-परवाही के चलते ही तो हुआ है, अब डॉक्टर्स से जवाब मांगना और महिलाओं को इस दर्द से छुटकारा देने के लिए सब पुरुषों को भी मेनका गांधी के साथ खड़ा होना चाहिए, लेबर के पैन को कम करने की अव्यश्यक्ता है !
After Maneka Gandhi Cracks Down On Caesarean Deliveries and calls it as a racket, sharing what UK Supreme Court observed 2 years back on choice of Women to decide mode of delivery… .
“Giving birth in the ‘NATURAL’ way or giving birth by ‘CAESAREAN SECTION’ (unless she lacks the legal capacity to decide)” is the choice of a Pregnant woman !!!
“Gone are the days when it was thought that, on becoming pregnant, a woman lost, not only her capacity, but also her right to act as a genuinely autonomous human being”
“It’s wrong to say that vaginal delivery is in some way morally preferable to a caesarean section: so much so that it justifies depriving the pregnant woman of the information needed for her to make a free choice in the matter.”
Law studying is a continuous process and it has no geographical barriers and sometimes one may come across such important decision, knowledge of which might be an added advantage.
I came across a Landmark and interesting judgment delivered by UK Supreme Court, dated 11th March, 2015, in the case of Montgomery (Appellant) v Lanarkshire Health Board (Respondent) (Scotland), wherein the Court allowed the appeal of Mrs. Montgomery and observed as above.
( you may see the link https://www.supremecourt.uk/…/d…/UKSC_2013_0136_Judgment.pdf )
Before we start further discussion, I would like to clear the doubt that this a Judgment of (Apex) Foreign Court and its not directly binding upon Indian Courts , nevertheless the approach of the Court may help the professionals in their practice and its persuasive value cannot be denied.
The Facts in nutshell are as under :
The Appellant Nadine Montgomery, an insulin dependent diabetic lady gave birth to a baby boy on 1 October 1999 at Bellshill Maternity Hospital, Lanarkshire. As a result of complications during the delivery, the baby was born with cerebral palsy of a dyskinetic type & Erb’s palsy (i.e. paralysis of the arm) & hence she claimed the damages on behalf of her Son. It was contended that she ought to have been given advice about the risk of shoulder dystocia (the inability of the baby’s shoulders to pass through the mother’s pelvis) which would be involved in vaginal birth, and of the alternative possibility of delivery by elective caesarean section. Mrs Montgomery was told that she was having a larger than usual baby. But she was not told about the risks of her experiencing mechanical problems during labour.Women with diabetes are more likely to have large babies and there is a 9- 10% risk of shoulder dystocia during vaginal delivery Though this may be resolved by emergency procedures during labour, shoulder dystocia poses various health risks to the woman and baby. Mrs Montgomery had raised
concerns about vaginal delivery to her Doctor Mrs. Mclellan, but Dr McLellan’s policy was not routinely to advise diabetic women about shoulder dystocia as, in her view, the risk of a grave problem for the baby was very small, but if advised of the risks of shoulder dystocia women would opt for a caesarean section, which was not in the maternal interest.
The Appellant lost in lower Courts.Lord Ordinary in lower Court rejected the contention of the Appellant that she should have been informed of the risk of shoulder dystocia if vaginal delivery was proposed and that she should have been advised about the alternative of delivery by caesarean section.Lord Ordinary held that whether a doctor’s omission to warn a
patient of risks of treatment was a breach of her duty of care was normally to be determined by the application of the “Bolam test” (Bolam v Frierm Hospital Management Committee [1957] i.e., whether the omission was accepted as proper by a responsible body of medical opinion, which could not be rejected as irrational and Given the expert medical evidence for the Board, the Bolam test was not met. Lord Ordinary further observed that the risk of shoulder dystocia, though significant, did not in itself require a warning since in most cases shoulder dystocia was dealt with by “simple procedures” and the chance of a severe injury to the baby was “tiny”.
The Inner House of Session refused Mrs Montgomery’s reclaiming motion and upheld the Lord Ordinary’s conclusion
However, their Lordships of the Supreme Court turned down the observations of both the lower Courts and allowed the Appeal.
LADY HALE in her concurring judgment discussed more about the right of women in selecting mode of delivery and her Ladyship observed “the issue is not whether enough information was given to ensure consent to the procedure, but whether there was enough information given so that the doctor was not acting negligently and giving due protection to the patient’s right of autonomy”. She further observed, Pregnancy is a particularly powerful illustration. .
The principal choice is between vaginal delivery and caesarean section. In this day and age, we are not only concerned about risks to the baby. We are equally, if not more, concerned about risks to the mother. And those include the risks associated with giving birth, as well as any after-effects. One of the problems in this case was that for too long the focus was on the risks to the baby, without also taking into account what the mother might face in the process of giving birth.
Her Ladyship criticized the decision of Dr. Mclellan and observed that ” Dr. Mclellan’s judgment is not a medical judgment but Giving birth vaginally is indeed a unique and wonderful experience, but it has not been suggested that it inevitably leads to a closer and better relationship between mother and child than does a caesarean section.”
“Pregnant women should be offered evidence-based information and support to enable them to make informed decisions about their care and treatment. Her Ladyship observed while concluding her judgment !!!!
In India, Doctor-patient relationship is on roller-coaster and is always looked from yellow glasses… If a Doctor advises for any Test, and if the report is in favour of patient, it may be called as unnecessary test to grab Commission.. and on the contrary if the said Test is not advised, Doctors have fear of receiving Court Summons ! There are no 2 opinions that bad elements also exist in the Medical profession.. But can we apply same yardstick to every1 ?
One more point, can the cost of Normal and C Section deliveries be kept at par, to end the controversy ?
Nevertheless, C-Section or Normal delivery bonafide informed advice of Drs must be adhered to than the personal choice… , in my opinion….
thanks and Regards
Adv. Rohit Erande
Pune.©