Karnataka hospitals are conducting way too many C-section deliveries and the state government wants it brought down to acceptable levels.
Consequently, Health Minister K Sudhakar announced on Wednesday, 16 November, that plans were in the pipeline to set up a committee to check on the number of C-section deliveries across the districts.
Sudhakar made the announcement after visiting Tumakuru district hospital, which not only has the highest number of C-section deliveries in the state, but also allegedly sent back a pregnant woman recently without treatment, which led to her death along with her twins.
“The aim is to ensure that the number of caesarean deliveries is brought down to a great extent,” said Health and Family Welfare Commissioner Randeep D.
Above average rates
As per the recommendation of the World Health Organization (WHO), the number of C-section deliveries in a country should ideally be under 15 percent.
As per NITI Aayog’s report “Best Practices in the Performance of District Hospitals” released in October 2021, the national average is 20.9 percent.
But if the national average is considered unacceptable by WHO standards, that of Karnataka is way above it — 38.45 percent.
Worse, 18 of the state’s 31 districts have a rate above the state average, with seven of them above the 50 percent-mark:
- Tumakuru: 62.7 percent
- Chitradurga: 58.2 percent
- Udupi: 55.6 percent
- Chikkaballapura: 54 percent
- Chikkamagaluru: 53.9 percent
- Bengaluru Rural: 53.9 percent
- Ramanagara: 51.9 percent
Only one Karnataka district is below the threshold limit set by WHO: Yadgir, at 9.4 percent. While one is below the national average: Vijayapura at 16.5 percent; while Raichur is just above it at 21.6 percent.
Tumakuru consistently high
Statistics available with South First shows that Tumakuru district has kept above the 60 percent C-section delivery rate consistently over the past seven months.
As per data, the number of C-section deliveries in the district were:
- April: 60.6 percent
- May: 63.1 percent
- June: 62 percent
- July: 65 percent
- August: 63 percent
- September: 62.7 percent
- October 62.5 percent
Chitradurga too has shown consistent increase over these months:
April: 56.4 percent
May: 58.5 percent
June: 55.5 percent
July: 57.6 percent
August: 59.5 percent
September: 58.8 percent,
October: 61.3 percent
The government has noted the upward curve in the districts and especially Tumakuru, the health commissioner said.
“The reason being given is that there are many referral patients, who are come from neighbouring PHCs at the late stages,” he explained, referring to public health centres in the smaller towns.
Moreover, complications are arising because these cases are at the late stages of pregnancy, which necessitates C-section deliveries.
“However, now a committee will look into this,” Randeep said.
Fear of losing baby
Despite its high C-section delivery rates, Karnataka has been faring better than other southern states in the country, any northward trend needs to be brought down “as and when noticed”, conceded its maternal health programme officer, Dr Rajkumar N.
In fact, he said, “now” is the right time to control this trend.
Among the reasons for the increase in caesarean deliveries, especially in district hospitals, is mainly the fear among both patients and doctors of losing the baby after a long labour.
“Patients are worried they may lose their babies, and doctors seem not to be ready to take any risks,’ Dr Rajkumar told South First. “So when the doctor suggests a C-section, the patient is ready to jump in.”
His view: “This has to be avoided.”
The lure of money
There is another reason: Financial returns for doctors if they perform the C-section.
A senior doctor from a district hospital said, often, a case is “made to look complicated”, especially during the last months of pregnancy.
This is how it works: Patients are given an option for C-section at either a private hospital, which would cost almost three times the rates at government hospital, or get it done with the same doctor at a higher cost.
Usually, patients are more comfortable with the attending doctor, and when they are unable to afford a private hospital, the vote for a C-section is a cinch, explained the doctor.
“The number of such cases may be five in 15, but they are happening.”
Fear of litigation
There is a third — and very potent — reason why doctors suggest C-sections: Their fear of the consequences if anything goes awry during of delivery.
“Doctors are cautious because they want to avoid litigation, court cases or being beaten up by the patient’s relatives,” said an obstetrician and gynaecologist from one of the district hospitals.
According to her, there have been many cases when still-born babies have been delivered after a tedious labour that has lasted some 12-14 hours.
“In such cases, it is the doctors who are blamed for not opting for a C-section, and they are often beaten up.”
Often, the reason for C-section deliveries are genuine concerns stemming from the lifestyle of the expectant mother.
This is especially true with women who lead sedentary lifestyles and have unhealthy eating habits, or suffer from malnutrition.
“Such women tend to have ailments like hypertension and diabetes,” explained Dr Rajkumar.
“This adds to complications and doctors might want to avoid vaginal deliveries in such cases.”
When do you need C-sections?
Caesarean sections can be lifesaving in many cases, explained Dr Gopikrishna T, obstetrician and gynaecologist and paediatrician from Sevakshetra Hospital in Bengaluru.
“Sometimes, there are conditions when the C-section is not only preferable but mandatory,” he said.
For instance, Dr Gopikrishna explained, it is advisable in situations that involve “placenta previa”, where the placenta completely or partially covers the opening of the uterus (cervix). “Going into labour in that condition can lead to life-threatening haemorrhage in patient,” he said.
There may also be cases of “cord prolapse”, a condition that occurs when the umbilical cord drops (prolapses) between the fetal presenting part and the cervix into the vagina. “This can cause the death of the baby.”
Other conditions that Dr Gopikrishna cited for C-sections are an expectant mother with small bony pelvis, a large (macrosomic baby), obstructions at the vaginal outlet, or some sort of foetal distress.
“One must however remember that with C-sections also comes greater risks than vaginal births,” Dr Gopikrishna said.
“This is a major surgery and seven layers of the abdomen needs to be cut and stitched back,” he explained.
Plus, said Dr Rajkumar, this kind of delivery can lead to more blood loss, chance of infection or blood clots, complications for the woman for future pregnancies etc.
“Though there is no rule that the second baby should also be delivered via C-section, the chances of such a delivery are high if the first delivery is C-section,” he said.
Efforts to reduce C-sections
While making the announcement regarding plans to bring the number of C-sections under acceptable levels in the district hospitals, the health minister however cited targets above that recommended.
“C-section deliveries should generally remain within 20-40 percent of the total deliveries,” he said.
The minister also emphasised that such deliveries were not recommended when normal delivery is feasible.
“If this is being done deliberately we will take strict action to stop this,” he said.
Meanwhile, district surgeons across the hospitals have been instructed to hold weekly review meetings with all department heads, health commissioner Randeep told South First.
“The number of C-sections has to be brought down to 30 percent. Also, four antenatal check-ups are very important and the attending doctor should ensure that the patient and her family are counselled on the importance of normal delivery,” Randeep said.
Audits for C-sections planned
The state has begun auditing all C-section cases that have happened in the district hospitals across the state over the past few months.
“The surgeon who has conducted the operation will have to explain reason,” Dr Rajkumar told South First.
“The process started last month and we are already seeing a 2-6 percent reduction in C-sections in some of the districts after this move,” he said.
The health department is also taking steps to beef up its monitoring systems. For instance, Dr Rajkumar said, the weekly review meetings have been made compulsory, with the commissioner, director and principal secretary looking into the progress made by each district in reducing caesarean deliveries.
“Many people believe that C-section is an elective surgery and can be opted for by the patient, which is not true,” he said.
“Like euthanasia, this surgery is also cannot be decided on by the patient. Unless and until the scan reports or other health parameters calls for a C-section, the patient cannot opt for this surgery.”
Scenario at private hospitals
Though the number of C-sections, as per Dr Rajkumar, is around 50 percent in the private sector, Federation of Obstetrics and Gynecological Societies of India (FOGSI) President Dr Hema Divakar says, “We from FOGSI are insisting that every obstetrician and gynecologist should classify C-setion as per Robsons criteria.”
This is real-time data on pregnancies and caesarean sections and that will be classified under the Robson chart which classifies all deliveries into one of 10 groups on the basis of five parameters.
“Obsteric history, fetal lie, number of neonates and gestational age and onset of labour. The 10 groups also include twin deliveries, the child’s position being unfavourable for delivery, previous delivery by C-section etc,” she explained.
This will give a clear idea of avoidable C-sections without compromising on safety and outcomes.
This data, Dr Hema told South First,has to be presented to the government and to FOGSI.
“Going by absolute numbers will not get us anywhere. Supervised deliveries in the peripheral centres and timely transfers have reduced the C-sections. Data of private hospitals will soon be analysed and published,” she said.