This article is written by our intern Ms. Navita, who is a second year student, pursuing B.A. LLB (hons.) from Rajiv
Gandhi National University of Law, Punjab.
Introduction:
The cesarean section (C-Section), a vital medical
intervention, has witnessed a concerning rise in India, particularly within
private healthcare settings. While crucial in mitigating childbirth risks, its
overutilization beyond recommended thresholds poses significant health,
economic, and legal challenges. This article examines the multifaceted factors
driving this surge, its implications on maternal and neonatal health, and the
legal complexities surrounding cesarean deliveries.
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Defining cesarean
section
The C-section, stands as a pivotal medical
intervention, safeguarding the lives of mothers and infants in precarious
childbirth scenarios. This surgical procedure, warranted in instances of
obstructed labor, fetal distress, or maternal complications, ensures the
delivery of infants when vaginal birth poses substantial risks. However, its
judicious application is imperative, aligned with the World Health
Organization's (WHO) directive advocating for its usage solely in medically
indicated circumstances.
In the context of India's healthcare landscape, a
concerning trend has emerged within private hospitals—the escalating rates of
cesarean sections have increased beyond the WHO's recommended threshold of 15%. This trajectory underscores
the imperative to delve deeper into its ramifications on women's health,
postoperative conditions, and the legal labyrinth enveloping childbirth
practices.
Factors
Contributing to the Surge in Cesarean Section Rates
The escalating
prevalence of cesarean sections in India's private hospitals can be attributed
to several intertwined factors, each exerting a significant influence on
childbirth practices.
1. Rise in Institutional Births and Unregulated Health Facilities: A notable driver behind the surge in cesarean deliveries is the burgeoning trend of institutional births, particularly within private healthcare facilities. The proliferation of unregulated health institutions, has created an environment conducive to the overutilization of cesarean sections. In the absence of stringent oversight, profit motives often overshadow clinical considerations, leading to an unwarranted inclination toward surgical interventions.
2. Lifestyle Factors and Obesity Prevalence: Urbanization and shifting dietary patterns have increased a rise in sedentary lifestyles, contributing to an alarming increase in obesity rates among women. The confluence of this lifestyle predisposes women to complications during childbirth, rendering them more susceptible to cesarean deliveries. Obesity not only complicates the process of labor but also necessitates surgical interventions to mitigate associated risks, thereby exacerbating the prevalence of C-sections.
3. Fear of Childbirth Complications and Secondary Infertility: For women grappling with secondary infertility, the specter of childbirth complications looms large, instilling a pervasive fear of pursuing vaginal delivery. The desire to maximize the chances of a successful live birth often prompts these women to opt for cesarean sections, viewing it as a safer alternative despite potential risks. This fear-driven decision-making process further perpetuates the escalating rates of cesarean deliveries, particularly within the private healthcare domain.
4. Economic Considerations: The economic dimension also plays a pivotal role in fueling the surge in cesarean section rates. While cesarean deliveries entail higher costs compared to vaginal births, they offer healthcare providers a lucrative revenue stream. The expedited nature of cesarean sections translates to shorter hospital stays and reduced resource allocation, thereby maximizing profitability. This financial incentive, coupled with the perception of convenience and expediency associated with cesarean deliveries, incentivizes healthcare providers to favor surgical interventions over natural childbirth.
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Data Insights
In the Indian context, data from the National Family Health Survey (NFHS-4) reveals that 17% of live births in the five years preceding
the survey were delivered via cesarean section, with a significant portion
(45%) of these cesarean deliveries being planned after the onset of labor
pains. Notably, the prevalence of cesarean sections has surged over time, with
NFHS-3 reporting a rate of 8.5%, which escalated to 17.2% in NFHS-4 and further
climbed to 21.5% in 2019-21. Disparities based on
geographic and socioeconomic factors are apparent, as women residing in urban
areas and those with higher levels of education exhibit higher likelihood of
undergoing cesarean deliveries. Specifically, women with bachelor's degrees
delivering in private facilities have been observed to have 11 times greater odds
of delivering via cesarean.
Furthermore, the odds
of cesarean deliveries are markedly higher in private hospitals compared to
public hospitals. District Level Household Survey-4 (DLHS-4) data indicate that
while 13.7% of births occur in public hospitals, a staggering 37.9% of births
in private facilities are through cesarean section. This trend is
corroborated by findings from the NFHS, highlighting a decline in cesarean
deliveries in public hospitals from 15.2% to 11.9% between 2005-06 and 2015-16
in cesarean deliveries in private healthcare providers during the same period.
The escalation in cesarean section rates
raises concerns not only due to associated health risks but also due to
manifold increases in healthcare expenditure, particularly in private
healthcare settings in India. The costs associated with cesarean deliveries are
substantially higher than those of non-cesarean deliveries, exacerbating
financial burdens on families. Moreover,
the discrepancy in costs between cesarean and non-cesarean deliveries
perpetuates healthcare inequities, disproportionately affecting marginalized
and economically disadvantaged populations who may already face barriers to
accessing quality healthcare services.
Alarmingly, a substantial proportion of
cesarean deliveries in India are deemed avoidable which reflects a systemic
issues of over-medicalization and inappropriate utilization of surgical
interventions. The potential cost savings of $320.60
million, as estimated if private sector facilities had adhered to the
WHO's recommended threshold of 15% cesarean delivery rates, underscore the
magnitude of this issue. These savings could have been redirected towards
strengthening maternal and neonatal healthcare services, improving access to
prenatal care, and implementing evidence-based interventions aimed at reducing
maternal and infant mortality rates.
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Explanation
High Cesarean Section Rates in Teaching Hospitals
The prevalence of
cesarean sections (CS) in teaching hospitals is notably high, driven by several
interrelated factors intrinsic to medical education and the broader healthcare
landscape in India.
1.
Training Imperatives and Learning Environment: In
teaching hospitals the CS rate is generally high. To learn the caesarean
technique, students particularly those doing post graduation in gynaecology and
obstetrics may perform caesarean when it is not required. The imperative to impart practical
experience in CS techniques may inadvertently lead to the performance of
cesarean deliveries when not clinically warranted, as students seek to hone
their skills under supervision.
2.
Infrastructure Deficiencies and Population
Pressure: India's burgeoning population exerts immense
pressure on healthcare infrastructure, particularly in the realm of obstetric
care. Many public and private healthcare institutions lack essential
infrastructure for proper vaginal deliveries, including adequate beds,
electronic fetal monitoring systems, skilled neonatal intensive care, and blood
transfusion facilities. In such resource-constrained settings, healthcare
providers may opt for CS as a perceived safer alternative to mitigate potential
risks associated with vaginal delivery.
3.
Demand from Affluent Urban Women: The rising demand for elective cesarean sections among highly educated,
affluent urban women further contributes to escalating CS rates. Motivated by a
desire to avoid labor pain and influenced by cultural perceptions and
preferences, these women may opt for cesarean deliveries.
4.
Doctor-Patient Dynamics and Reputation: Patient preferences, particularly the desire for a specific
obstetrician with a reputed track record, can influence the decision-making
process regarding childbirth methods. In instances where doctors maintain busy
schedules or where patients express explicit preferences, elective cesarean
sections may emerge as a favored option, aligning with both patient and
provider expectations. Sometimes doctors recommend to opt CS owing to the fact
that it takes lesser time than a normal delivery. This dynamics, thus,
influence patient’s decisions as well.
5.
Limited Access to Pain Management Options: Unlike developed countries where painless vaginal deliveries are
commonplace, India faces a dearth of anesthesia services and infrastructure to
support pain management during labor. The unavailability or lack of painless
labor options, coupled with the time-consuming nature of such procedures for
both doctors and patients, further exacerbates the inclination towards cesarean
deliveries.
After effects of Cesarean Delivery
While cesarean delivery
undoubtedly serves as a life-saving intervention in certain obstetric
circumstances, its judicious utilization is paramount, given the documented
adverse consequences for both maternal and neonatal health outcomes.
1.
Neonatal Health Implications: Infants born via cesarean delivery are at heightened risk of various
negative health outcomes, as evidenced by research findings. These include an
increased likelihood of childhood obesity, respiratory disorders, type 1
diabetes, acute lymphoblastic leukemia, impaired cognitive development, and
higher rates of autism and neurodevelopmental disorders. These aftereffects
underscore the importance of cautious consideration when opting for cesarean
delivery, particularly in cases where vaginal delivery is feasible.
2.
Maternal Health Risks: The aftermath of cesarean delivery extends beyond neonatal health
implications, encompassing elevated risks for maternal health. Studies indicate
that cesarean delivery is associated with approximately a four-fold increase in
the risk of maternal death compared to vaginal delivery. This heightened risk
underscores the imperative for careful assessment of maternal indications for
cesarean delivery and the provision of appropriate preoperative and
postoperative care to mitigate adverse outcomes.
3.
Economic Burden: Beyond the health consequences, unnecessary cesarean deliveries impose
a significant economic burden, particularly in low-income settings. The
increased healthcare costs associated with cesarean sections, coupled with the
potential for adverse health outcomes, underscore the importance of judicious
utilization of this surgical intervention. Initiatives aimed at optimizing
childbirth practices and promoting evidence-based decision-making can help
alleviate the economic strain associated with unnecessary cesarean deliveries
while ensuring optimal maternal and neonatal outcomes.
Legal Consequences of Increasing C-Section Deliveries in Private
Hospitals
The legal framework surrounding C-sections in India is a work in progress. While there are no specific laws directly regulating C-section rates, existing legal principles can be applied to address concerns about informed consent and potential misconduct by medical professionals. The "Code of Medical Ethics Regulations, 2002" underscores the primary objective of the medical profession as serving humanity, with financial gain being a secondary concern (Clause 1). Additionally, Clause 2.3 emphasizes the importance of providing accurate prognoses, prohibiting physicians from either exaggerating or downplaying the severity of a patient's condition.
1. Uninformed Consent: No Consent, Potential Offense
Hospitals and medical practitioners have a duty to ensure that patients understand the risks and benefits of different delivery options and are given the opportunity to make informed choices about their care. Performing unnecessary c-sections without proper consent undermines patient autonomy and may constitute medical negligence.
If a patient gives
consent for a normal vaginal delivery, hospitals should not perform a c-section
without the patient's explicit consent or unless there is a clear medical
indication necessitating the procedure. Citing potential risks associated with
pregnancy, such as fetal distress or maternal complications, as grounds for
performing a c-section when they are not imminent or unavoidable could be
considered a violation of the patient's right to informed consent.
In Samira
Kohli v. Dr. Prabha Manchanda,
the Supreme Court ruled that consent given for a diagnostic procedure or
surgery does not automatically extend to therapeutic surgery unless there is an
immediate threat to the patient's life or health. The court emphasized the
importance of obtaining "real and valid" consent from patients,
ensuring that they are provided with adequate information to make informed
decisions about their treatment.
In the case of the Indian
Medical Association vs. V.P. Shanta
and Ors., the Supreme Court clarified that the medical
profession falls within the scope of the Consumer Protection Act, 1986. This
landmark decision removed ambiguity and established that all patients,
including those receiving free treatment, are considered consumers. This
decision is relevant in cases of medical malpractice in c-section deliveries,
particularly when the procedure is performed unnecessarily. If a doctor
performs a c-section without a valid medical reason, it constitutes negligence
and can lead to legal action under consumer protection laws.
2. Violation of Doctor's Duty: More
Than Just a Procedure
Doctors have a professional and ethical duty to act in
the best interest of their patients. Performing unnecessary C-sections can be
seen as a violation of this noble duty. Medical councils in India have the
authority to take disciplinary action against doctors who engage in practices
detrimental to patient welfare. Performing unnecessary C-sections purely for
financial gain or convenience could be considered professional misconduct.
In the case of Dr.
Laxman Balkrishna Joshi vs. Dr. Trimbark Babu Godbole and Anr., and A.S.Mittal v. State of U.P., the Supreme Court established that doctors
owe certain duties to their patients, including the duty of care in deciding
whether to take on a case, the duty of care in determining treatment, and the
duty of care in administering that treatment. Failure to fulfill any of these
duties may result in a cause of action for negligence, allowing the patient to
seek damages.
Conclusion
In light of these legal
principles, the healthcare sector must prioritize patient well-being over
financial incentives, adhering to professional codes and constitutional
mandates to uphold the right to health and dignity for all individuals. Any
deviation from these principles, such as undue financial incentives leading to
unnecessary C-sections or misinformation provided to patients, would not only
contravene medical ethics but also undermine the fundamental rights enshrined
in the Indian Constitution. Effective regulation and oversight are imperative
to uphold these standards and protect the health and dignity of individuals
seeking healthcare services in private hospitals.
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