8866.pdf
Media
- extracted text
-
BURDEN, CAUSE AND
COST OF CAESAREAN SECTIONS
K. Hemachandran
ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES
Sree Chitra Tirunal institute for Medical Sciences and Technology
Thiruvananthapuram, Kerala 695 Oil India
WORKING PAPER SERIES
BURDEN, CAUSE AND COST OF
CAESAREAN SECTIONS
A Community based Study in the three City Corporations of
Thiruvananthapuram, Kochi and Kozhikode, Kerala
K. Hemachandran
Working Paper No. 2
May 2003
ACHUTHA MENON CENTRE FOR HEALTH SCIENCE STUDIES
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Medical College P.O., Thiruvananthapuram, Kerala 695 011 India
Tel: 91-471 -2524140, Fax: 91-471 -2446433
Email: amchss@sctimst.ac.in, Grams: CHITRAMET
Website: http://sctimst.ac.in
Burden, Cause and Cost of Caesarean Sections
K. Hemachandran
English
Working Paper
Rights reserved
First published in May 2003
Printed at:
St. Joseph’s Press for Achutha Menon Centre for Health Science Studies
Series Editors :
Dr. D. Varatharajan and Dr. P. Sankara Sarma
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology (SCTIMST)
Medical College P.O., Thiruvananthapuram 695 011, Kerala, India
Tel : 91-471-2524241, Fax : 91-471-2446433
Email : dvrajan@sctimst.ac.in
Layout:
Giji and Radhika, Documentation and Publication Cell, AMCHSS
2
tOO
0 8 8b6
BURDEN, CAUSE AND COST OF
CAESAREAN SECTIONS
A Community based Study in the three City Corporations of
Thiruvananthapuram, Kochi and Kozhikode, Kerala
ABSTRACT
Mortality and morbidity for mother and baby are high due to Cesarean Section (CS)
compared to vaginal delivery. The C-section rate in Kerala has been increasing over the last
few years as indicated by various health surveys. This paper looks at the prevalence, cause
and cost of C-section in three city corporations of Kerala.
Three hundred and sixty mothers (120 each from each city), who delivered babies between
January 01,2000 and December 31,2000, were identified using cluster-sampling technique.
A pre-tested questionnaire seeking information on date and time of delivery, parity, mode
of delivery, age at marriage, education, place of delivery, number of ante-natal visits, socio
economic status (SES) ultrasound scanning (USS), sex and birth weight of the baby,
and the direct cost for the delivery was administered to them by a physician. Bivariate
and multivariate analyses were used to find out the relation, if any, between the predictor
variables and C-section.
All the 360 mothers delivered in an institution and more than half the deliveries (53.3%) were
in private health institutions. Overall prevalence of C-section was 34.4% (95% Cl 29.5 -
39.3). Factors like SES, educational status, age, place of delivery, time of delivery, number
of antenatal visits, number of USS and birth weight were found to be positively associated
with C-section rate in bivariate analysis. However, in multiple logistic regression analysis,
delivery during day time (OR 1.6, 95% Cl 0.9 - 2.9) compared to night time, birth weight of
more than 3500 gram (OR 3.8, 95% Cl 1.3 - 11.4) compared to 2500 grams and three or
more USS (OR 19.5, 95 % Cl 4.9 - 77.1) compared to no USS during the antenatal period
were associated with a high proportion of CS. The extra cost of CS deliveries in the three
cities of Kerala was estimated to be Rs. 2,53,37,488/C-section rate found by this study is much higher than the desirable standard (up to 15%) set
by the World Health Organization (WHO). Among the major determinants of high C-section
rate are non-clinical factors like time of delivery and more USS dominated over clinical factors.
Urgent policy decisions including auditing of each CS delivery are required in urban Kerala to
reduce the high rate of C-section delivery.
3
Working Paper Series - 2
INTRODUCTION
There has been much said and written in the past three decades about the high levels of
health standards achieved by the Indian state of Kerala. Many factors such as high levels
of female literacy and near equitable distribution of economic assets, together with the role
played by the health sector, both public and private, contributed towards this phenomenal
accomplishment. The Infant Mortality Rate (IMR) has hit a low of 16 per 1000 live births.’
Immunization coverage is scaling new heights and authorities are seriously reinforcing the
near 100% antenatal coverage to a minimum of 5 visits during each pregnancy against the
nationally accepted minimum of 3. Kerala's life expectancy too is the highest in the country.
In short, every thing looks headed in the right direction. But statistics given out by a recent
study by a state level NGO reveal a disturbing trend: an unprecedented increase in the
percentage of C-sections over the past two decades. A closer look shows that the trend is
not only continuing but is getting worse. Through the decades, feminists have complained of
the Medicalisation of pregnancy. Is this an extreme example of that? We should also look at
one health indicator in which Kerala is lagging behind many other states of India, that of
Maternal Mortality Rate (MMR). The MMR2 of Kerala to be 192 per 100,000, much behind
our next-door neighbour, Tamil Nadu.
One can argue that institutional deliveries bring with it the risk of higher proportion of C-
sections too. The WHO has suggested that 15% C-sections in all deliveries is more or
less the acceptable limit internationally. The proportion of institutional deliveries in Kerala
is a very high 97% in 19963 which is comparable with that of the developed countries. The
percentage of C-sections in Kerala rose from 11.9% in 1987 to 21.4% in 1996.4 There is
variation across sectors - C-section rate ranges from 10% in public to 30% in private sector.4
The proportion of C-sections is considerably higher in urban areas than the rural areas.5
The reasons for this are many. Medical records will be misleading, as they often cite the
indication for C-section as emergency intervention in face of maternal or foetal distress.
But insiders tell a different story. Real reasons are often non-clinical and doctors may advice
a C-section for a patient even when it is not clinically indicated for reasons of their own.
There are instances where doctors working in some private institutions are pressurised
by the hospital management to promote C-sections as it brings in more revenue. Health
5
Burden. Cause and Cost of Caesarian Sections
economists term it as ‘provider induced demand' There are also reported instances where
women themselves or their family members have requested a surgical intervention for the
sake of the baby being born on an astrologically auspicious day!
Increase in C-section rate is disturbing, as it puts additional burden on the women in the
form of unwanted morbidity and high economic cost. However, exact magnitude of the
problem and the reasons are still unknown. This paper sets out on this venture. The broad
aim is to estimate the burden of C-section, its determinants and cost in three city corporations
of Kozhikode, Kochi and Thiruvananthapuram in Kerala. Specific objectives are:
1.
To quantify the prevalence of C-section and compare and contrast it with WHO norms;
2.
To identify clinical and non-clinical factors associated with high prevalence, if any;
3.
To estimate the treatment and other costs attributable to C-section.
C-Section - The Operation
The origin of the word Caesarean is uncertain but probably derives from the Latin verb
caedere meaning 'to cut’. By definition, C-section refers to the delivery of a foetus through an
incision on the abdominal wall and the uterus and it does not include surgical procedures
undertaken to remove the foetus from the peritoneal cavity after partial or complete rupture
of the uterus, or in case of abdominal pregnancy. There is the Classical C-section where a
longitudinal incision is made in the upper segment of the uterus and the Lower Segment
Caesarean Section (LSCS) with a transverse incision in the lower segment. The Classical
CS is now resorted to only if there is some contra indication for doing a LSCS.
The oldest authenticated record of a live child being born by this method occurred in Sicily
in 508 BC. Upto the 16m century, the operation was mainly carried out to save the life of
the child in the event of the death of the mother, and this is still resorted to today on occasion.
Trautmann performed the first verifiable C-section on a living woman in Wittenberg in Germany
in 1610 AD; the patient died 25 days later. It was not until late 19m century that the uterine
incision became routine, with consequent improvement in maternal mortality. The first
satisfactory method for suturing the upper segment incision was described by Sanger in
1822. Kehere and Munro Kerr pioneered and perfected the Transverse Lower Segment
incision in 1911.
6
Working Paper Series - 2
The advent of modern antibiotics and improvements in surgical technology and support
mechanisms have helped to increase the popularity of C-section among the providers as
well as to reduce the apprehensions of the potential subjects. Incidentally, this has given
rise to a new set of ‘indications’ for the Caesarean section. The major indications are:
1.
Cephalo-pelvic disproportion and contracted pelvis
2.
Dystocia due to soft parts
3.
Inadequate uterine forces
4.
Ante-partum hemorrhage
5.
Pre-eclamptic toxemia
6.
Eclampsia
7.
Fetal distress and prolapse of the cord
8.
Mal-presentation
9.
Bad Obstetric history like difficult deliveries or perinatal deaths
10.
Elderly Primi Gravida
Regional spinal anaesthesia is the commonly used and General anaesthesia is resorted to
only when there are other complications. There are a number of immediate complications
like haemorrhage, infection, thrombo-embolism, wound dehiscence and paralytic ileus
that can arise from a CS. Late complications include utero-parietal fistula, scar endometriosis
and rupture of scar during subsequent pregnancy.
Indications and Reasons for C-section
Standard textbooks give many indications for CS, and they also rank them in an order of
frequency of incidence. The ranking order available from other studies does conform to this
order.6’7 8But factors like pressure from the patients and the physician factors are often not
mentioned. Specific studies have been made to identify certain maternal factors (Non
Medical), which can influence the decision to go in for CS.
Rosenthal & Patterson9 (1998) have found a positive association with the maternal age and
the type of delivery. Webster et al ’°(1992) also have found similar findings where a higher
maternal age is one of the reasons for the type of delivery. Chacham and Perpetuo ”(1998)
7
Burden, Cause and Cost of Caesarian Sections
in a study conducted in Brazil have clearly shown the positive association between maternal
education and CS. The order of the birth is another factor which influences the type of delivery,
where the first order birth is more likely to have a CS. The birth weight of the baby also has
a positive association with babies weighing above 3000g having an increased chance for
going in for a CS.10'12
Physician/provider factors are also important. Lower tolerance for taking risks, fear of
litigation (earlier only in the western context but now increasingly in India too) etc is usually
quoted as the common physician related factors.’3-14 Physician convenience, physician 'style'
of practice, financial incentives experience and training, availability of a expert second opinion
were found to be factors associated with CS rates by some researchers.’5-16
Epidural anaesthesia has been blamed for the increased incidence of dystocia and so indirectly
CS. This is evident from various studies and is quoted in the ICAN website.'7 Most private
institutions provide Caesarean services on demand. In UK, an audit found that such demands
were often much respected by the obstetricians.'8 In Brazil, CS is often made use of in
performing surgical sterilization, as the accepted methods of family planning do not
include sterilization. There is also a perception among women that a CS will help them keep
their vaginal anatomy intact and will protect against loss of normal coital function. This
perception is encouraged by at least some Obstetricians. The reduced skill of the upcoming
Obstetricians in handling instrument-assisted19 delivery also is one of the reasons for the
rise in CS rates.20-
’’Treffers et al20have also suggested the needs for a larger role for the
midwives.
Risks of C-sections
Caesarean Sections, which can be unavoidable and life saving on occasions also carries
with it an additional burden of morbidity and even at times mortality to both the mother and
the baby.2'The risk of maternal mortality for CS in the USA is 20 per 100,000 as
compared to 2.5 per 100,000 for vaginal delivery.22 Mukherji et al23 have reported, that in
an Indian study, deaths related to CS accounted for one-eighth of all maternal deaths in the
hospital and the institutional mortality for CS was 5.7 per 1000. Apart from mortality, CS
poses documented medical risks like infections, hemorrhage, injury to associated organs,
complications of anaesthesia, possible transfusion reactions etc.'7 Boehm et al.24 (1994)
8
Working Paper Series - 2
reports the risk of maternal morbidity is about 8 to 12 times higher for CS compared to
vaginal delivery. The risk multiplies when primary CS leads to subsequent CS as repeat
sections carry higher risk to the mother.25
Petitti et al22, Bhargav (1998)26, Kamal et al.27 (1994) Pai et al28 (1999), and DiMatteo et al29
(1996), have all studied the effects of CS on maternal morbidity and reported significant
findings. They all have shown that CS can adversely affect breastfeeding. Incisional hernia
is one of the late complications, which is true for any abdominal surgery.22 Savage (1999)'4
stresses on the occurrence of placental anomalies in subsequent pregnancies.
Apart from physical morbidity, there is also the psychosocial morbidity that we have to consider.
The CS imposes a severe psychological stress on the mother and her family for years to
come.30 She goes on to quote different studies, which analyze the impact on the mother, the
infant, and the father jointly and separately. The impact the surgery per se has on the individual
can have long lasting effects. Oakley A. 3,(1983) has discussed the significance of trivialization
of the CS. He criticizes the medical education system for conceptualising and defining this
major surgical procedure as a routine alternate method of birthing rather than a ‘special
event or crisis’. The use of the term ‘section’ instead of a more likely surgical term like
‘hysterectomy’, according to Oakley is an attempt in this direction.
Ethical issues
Many authors have stressed the problem of ethical issues concerning the use of unnecessary
medical interventions.'4 Madhukar Pai asks how a country like India can afford such an
extravagance when we can hardly meet our basic requirements with our dwindling resource.28
In short, it seems to have left no doubts in anyone’s mind that the CS rates have increased
in the last decade, and is still rising. The time has come to sit up and take notice, and it is
worth reiterating the recommendation of the KSSP study of 1991 in Kerala, “there is a need
to de-emphasize the medicalization of such normal phenomena as pregnancy and child
bearing.”32
Caesarean Rates
The world is witnessing an unprecedented phenomenon in the increasing rates of certain
surgical interventions like the Appendectomy, Coronary Artery Bypass, Hysterectomy and
the Caesarean Section. Alarmed by the skyrocketing rates of these operations, the
9
Burden. Cause and Cost of Caesarian Sections
medical community has, at least in some developed countries, set up audit systems and this
has actually reversed these disturbing trends in some countries.'8 There were also certain
isolated attempts like the Mount Sinai CS reduction program and they have succeeded
in sustaining the CS rates at around 10-12% without any adverse effects.33 The story is
entirely different in the case of developing countries, where it is usually the largely unregulated
private sector that controls the lion's share of the health care market. Here, medical audits
are unheard of and will be resisted by all sections of providers. Studies prove that the rising
trend of these procedures continues and this shows no signs of stabilizing in the near future.
Of all, it is the Caesarean Section rate that has shown consistent gravity-defying trends.
There is no universally accepted optimal CS rate. The WHO, in April 1985, convened a
meeting in Fortaleza, Brazil, to formulate guidelines on ‘appropriate technology for birth’. It
clearly states that there is no justification for rates higher than 10 -15% in any region of the
globe. It also encourages the publishing of information on birth practices like CS by individual
hospitals. The World Health Organization has been advocating for the promotion of Vaginal
Birth After Caesarean (VBAC) wherever possible. The government of USA also has put the
optimum level at 15% in its ‘Healthy People Strategy, 2000’ report of 1991. But some experts
has put advocated a flexible range of 20-25% for developing countries where the population
is impoverished with poor reproductive health.
An editorial in 'The Lancet’18 says that in creating awareness and making information available,
the emphasis should be on comparisons of the implications of vaginal versus caesarean
delivery. According to them the uptake of CS in women who possess such information will
clearly be more appropriate than any of the “desirable targets” put forward by any agency.
Indian Scenario
In India, the research on such operative procedures also shows that it is the Caesarean
Section (CS) and the Hysterectomy that are leading the pack'. There has been very little
research in India on CS rates and its impact26, but internationally there have been many
studies that estimate the rates as well as analyze the impact of the rising CS rates."3-14-34 The
rate increased from 5% to 25% in fewer than twenty years.35 Savage et al ,3(1993)
estimated the rate in England to be around 12%. Notzon et al 3-(1985) provides some data
10
Working Paper Series - 2
on developing countries. Belizan et al36 (1999) who studied the situation in the Latin America
estimated that around 8,50,000 unnecessary CS are performed each year. They put the
overall CS rate in Latin America between 17 to 40%. They also demonstrated an association
between high SES and CS rates. But it is Chile that takes the cake with an average rate of
37% of CS.37 The rates in Brazil rose from 14.6% in 1970 to 31% in just ten years'9 In Asia,
rates are available for few countries like China where it rose from 4.7% to 22.5% in a period
of thirty years.37 As stated earlier the second most populous country in the world, India, does
not know what the national CS rate is!.28
Few Indian studies show that the situation is going from bad to worse. KSSP surveys in rural
Kerala indicate a steady growth in C-section rate.32-3 A teaching hospital in Calcutta shows
an unbelievable rate of 49.9%.23 Another study in Chennai gives a figure of 45.2%;28 it,
however, does not give any significant relationships between this high CS rate and factors
like SES, parity, literacy etc. An association between late initiation to breastfeeding and CS
could be seen from the data, though not statistically significant. Sabu S. Padmadas et al5
have reported a CS rate of 17 for urban and 11.3 for rural Kerala based on National Family
Health Survey (MCH & FP), 1992 - 93.5
A study undertaken by undergraduates of Medical College, Thiruvananthapuram, under
the guidance of the Community Medicine Department, shows that C-section rate grew
from 14.7% in 1990 to 21.6% in 1999. It is interesting to note that 'Cephalo-pelvic disproportion'
(CPD) is the first and 'previous CS’ third in the list of reasons quoted in the hospital records
as the indication for CS. According to the International Caesarean Awareness Network Inc.17
(ICAN) website, up to 77% of women for whom the indication for CS was CPD and tried
labour again for a subsequent delivery had a Vaginal Birth After Caesarean VBAC.
Approximately one-third of these women gave birth to babies that were larger than their
previous 'CPD' baby. The ICAN site goes on to claim that on reviewing all literature on VBAC
for the period from 1985-1990, the rupture rate of a previous CS scar was 0.22% (in developed
countries it is 0.18%) while the incidence of other obstetric emergencies like prolapsed cord,
placental separation is much above this mark at 1 -3%. This adds weight to the claim that the
old dictum of ‘once a Caesarean, always a Caesarean’ is outdated.
11
Burden, Cause and Cost of Caesarian Sections
CS rates are higher in private than in public sector and 32have demonstrated this in
Thiruvananthapuram. A study for ‘UNDP (1995) in the city of Thiruvananthapuram shows a
CS rate of 10% in public sector and 30% in private sector. One of the reasons why Kerala
is lagging behind as far as MMR is concerned could be its high and increasing Caesarean
rates.3 CS rates of some countries are given in Table-1.
Efforts to reduce CS Rates
Although several strategies have been suggested and tried to control the rising graph of
CS, Studnicki et al39 (1997) remarks that nothing worthwhile has come out of these efforts.
The American College of Obstetrics and Gynecology (ACOG, 94) has brought out a consensus
statement encouraging vaginal birth after previous CS (VBAC). In Canada, an attempt made
to influence practice by opinion leaders and respected professionals have been more effective
than audit or feedback in increasing the incidence of VBAC.40
Socol et al 41(1999), in a study of institutions, which have tried to reduce CS rates by following
the “active management of labour" technique, found that it was effective in some while a
failure in others. RCT of the same also showed mixed results.42 It is evident from the Myers
and Gleicher study that second opinion requirements and feedback mechanism have done
their bit to bring down the rates . Another way is reducing the fee for CS and increasing that
of vaginal delivery. Kabra et al43 (1994) reports that it was successful in a private hospital in
Jaipur. In Australia, an experiment making the fee for CS and vaginal delivery equal, failed
because the busy doctors felt that it is easier to do a CS than wait for a normal vaginal
delivery and the fee also is the same for both .
Cost of Caesarean Sections
Though data is not available in India, a CS means an extra week’s stay in the hospital
and other associated costs, which would be at least 2 - 3 times more than a vaginal delivery28.
In the UK, National Health Service data shows that a CS costs the NHS at least 1000 pounds
more than a vaginal delivery. Savage et al13 (1993) suggests that a reduction of CS rate by
1% can save the NHS seven million pounds each year. In Brazil, an increase of 1% in
the rate can cost the exchequer US $ 4,104,000/- each year19. The ‘Public Health
Citizen's Research Group’ of US estimates that in 1987 alone 2500 CS resulted in
serious infections which caused a loss of 1.1 million extra hospital days and cost over
$ 1 billion.17
12
Working Paper Scries - 2
Table-1. C-Section Rates Across the World
CS Rate
delivery (%)
Institutional
delivery (%)
Skilled
attendant
Year
Burkina Faso
1.3
43
41
88-93
Country
Africa
Egypt
6.6
33
46
91-95
Kenya
5.2
44
45
88-93
Morocco
3.5
37
40
90-94
Namibia
7.0
67
68
87-92
Niger
0.9
16
15
87-92
Rwanda
1.8
25
26
87-92
Uganda
2.6
35
38
92-95
Zimbabwe
6.0
69
69
91-94
36.4
92
97
91-96
Colombia
16.9
77
85
91-95
Dominican Republic
22.0
92
97
91-96
Guatemala
8.2
34
35
91-95
21.4
97
99
1996
Latin America
Brazil
Asia
Kerala (Rural)
Source: Aravindan and Kunhikannan, 2000.3
METHODS
From the literature on the topic and also from discussions with a cross section of doctors and
general public, we got a rough idea on what factors were likely to influence CS rates. This of
course, took into consideration the standard indications as quoted by the textbooks as well
as other factors, which we had reason to believe, would influence the rate.
Outcome Variables
C-section Rate is the proportion of C-section deliveries in hundred births.
Causes as reported by the subject.
Cost calculations are based on reported direct costs; indirect cost is captured to some extent.
13
Burden, Cause and Cost of Caesarian Sections
Predictor Variables
Maternal Age in completed years. The chance of a C-section delivery is expected to
increase as age advances. Mudaliar and Menon (Text Book of Obstetrics) explicitly state
that ‘elderly primiparas’ have an increased risk of Caesarean.
Parity. It probably exerts its influence in association with age. Primiparas below the age of
18 and above the age of 35 are said to be at risk of a CS.
Socio Economic Status. Studies indicate a strong association between SES and the type
of delivery, an increased CS rate for high SES. The subjects are classified into three categories,
upper, middle and lower.
Educational status of the mother (completed years of education). Studies also show a
strong association between educational status and CS rate. More educated the mother;
more is the chance of a Caesarean. This trend is more evident in developing countries;
however, of late, higher educated women in developing countries have actually started resisting
Caesarean delivery.
Height of the woman (in cm). Maternal height is said to have an important effect on the
outcome of pregnancy. Women of height below 135 cm are at high risk of CS.
Place of delivery (public/private). It is said that the CS rate is higher in private institutions.
Earlier studies provided evidence in this regard.
Type of institution (referral centre/specialist centre/others). There are reasons to
believe that institutions with specialist care and also operating room facilities will have a
higher C-section rate, because of many reasons, the most important being that more high
risk cases would be referred there.
Elective/emergency. Obstetricians argue that they do elective C-sections, succumbing to
the demands made by the patients and their bystanders. We wanted to capture this information
from the subject whether the surgery was planned in advance or undertaken as an emergency.
Time of delivery. A study in Brazil revealed that C-section rates peaked just before 5 o’
clock in the evening. The reasons are quite obvious and had nothing to do with the textbook
indications for C-section. ‘Physician convenience’ was the main ‘indication’.
Previous delivery (normal/c-section). Despite evidence to the contrary, the old adage of
‘once a Caesarean, always a Caesarean’ is still the byword in the Obstetric wards across the
state. This paper attempts to find out the percentage of VBAC in our sample.
14
Working Paper Series - 2
Complications during last pregnancy. It is well known that maternal complications like
PIH, DM, and PET are known indications for a CS.
Number of antenatal visits. Some authors and NFHS-2 have observed that more the number
of antenatal visits more are the chance for a C-section. They have also expressed the view
that, if the subject was seen at the ANC by an obstetrician, as against a General Practitioner
or a Health Worker, the chances for a CS are even higher.
Whether USS was done during last pregnancy, Number of times. This was also found to
have a linear relation with the risk of a CS.
Birth weight (in grams). Larger the baby, higher the chance for a CS.
Indication for CS. Here, we are only looking at the reported indications to compare it against
the standard set of indications.
Study Site
Kerala, the southern Indian state, comprises of 1.2% of India’s total geographic area and
3% of the population. The population as per 2001 census is 31.8 million. There are 5 city
corporations and three of them - Thiruvananthapuram, Kochi and
Kozhikode - were
chosen. Each corporation has 50 wards and each ward has a population of 6000 to 15000.
The chosen cities represent south, central and north of Kerala. Kerala, although a small
state, shows great variations in culture and practices across the regions and so our choice
is expected to be representative of all the regions.
Sampling
Multi stage cluster sampling technique was used to identify the subjects. This method was
pioneered and perfected over the years by UNICEF for assessing immunization coverage.
They used ‘thirty clusters of seven’ for their purpose, which was based on an assumed
prevalence of 50% and a precision factor of 10. A modification of this technique was used in
this study. We assumed a prevalence of 23% of C-sections in the community and a precision
factor of 5. The subjects of the study were women who had delivered between 1st January
and 31s' December 2000. Sample size was calculated using the formula :
n = {z2 * PQ} * d
A2
Where n = sample size, Z= Confidence limit factor (taken as 1.96 for 95% confidence
interval), P= Assumed proportion of C-section deliveries (taken as 23% based on previous
studies and after a series of discussions with key informants including leading Obstetricians
15
Burden, Cause and Cost of Caesarian Sections
and Public Health experts), Q = 1 - P, r= Precision factor (difference between assumed
prevalence and the lowest expected prevalence taken as 18%). So, r= 0.23 - 0.18 = 0.05, d=
design effect (taken as 1.2).
The formula Z2 PQ/r2 is for random sampling. As we used cluster-sampling method, an addition
of 20% (d) was made to the sample size, in order to reduce the design effect. The calculated
sample size was n= ((1.96)2 0.23 ’ 0.77 / (0.05)2) * 1.2 = 326
We took "30 clusters of 12” hiking the sample size to 360. The clusters were selected from
all three corporations that have fifty wards each. The population according to the 1991 census
was listed and cumulative population calculated. The sampling interval was calculated by
dividing each city’s population with the number of clusters (10). With the help of a random
number and sampling interval, 30 clusters (wards) in three cities were identified.
Study Design
This is a cross-sectional study. A house-to-house survey was conducted in each of the
chosen 30 clusters, 10 in each city. After identifying the cluster (ward), the main landmark of
the ward was ascertained from the local public. The left hand side of the main road from the
said landmark was surveyed. In each house we enquired whether the household had anyone
conforming to the subject definition. If yes, willingness to participate in the study was sought
and the subject was interviewed using the prepared questionnaire. The process continued
till the required number of samples from the cluster was finished.
In Thiruvananthapuram and Kochi, the survey was undertaken by the principal investigator
himself, and in Kozhikode, two external researchers collected the data under the direction of
the Investigator. They were nursing graduates who were trained for the purpose by the
principal investigator for two days. On the first day, the purpose of the study and the design
were explained to the researchers. They were then made to read the questionnaire and
translate it in to Malayalam. The mistakes were identified and corrected after which they
conducted mock interviews using the questionnaire. On the second day, they were
taken to the field, where they observed the principal investigator conducting interviews and
later they did the same under the observation of the investigator.
Duration
The duration of study was 45 days from the start of the survey in January 2001. Every day
the study started at 9 am and finished after the completion of one cluster. There were days
when one cluster was finished sufficiently early for us to begin work on the next. On such
16
Working Paper Series - 2
days, the remaining work in the cluster was finished first on the next morning before starting
on a fresh cluster.
Instruments
Questionnaire
Structured questionnaire was prepared after many rounds of discussion with the guides
and a thorough literature review. It was pre-tested and corrections were incorporated before
the start of the survey. Questions were aimed at capturing accurate information on
demographic characteristics, details on the delivery, costs and other predictor variables listed
above. One questionnaire took about 20 to 25 minutes to complete, including height
measurement. The socio-economic status was assessed by investigator’s subjective
assessment. It was primarily based on observing the type of the house, assets, and calculating
the per capita expenditure according to reported income and expenditure. There was a
prepared checklist against which items were matched and subjects were assigned to one of
the three socio-economic categories.
Plumb Line
Height was measured by making the person to stand against a wall with hip and heel straight
and head erect. It was measured with a graduated plumb line. The graduations were made
with colored thread on the line using a measuring tape.
Data Entry and Analysis
A codebook was prepared by the investigator to facilitate data entry. Data was entered in
Microsoft Excel Version.4.
It was then cleaned and analysed using SPSS for Windows
version 6.1. Bivariate and multi variate analysis were done to search for relations between
the predictor variables and CS deliveries.
Sample Characteristics
As mentioned earlier, 360 subjects from three different cities were interviewed during the
survey. Majority (78.1%) of the subjects belonged to the age group of 21-30 years. Age at
marriage for women in Kerala is higher than the national average and our sample reflects
this fact; the lowest age was found to be 18 years with the mean of 25.53 years.
RESULTS
In the study population, majority of the subjects belonged to middle socio-economic
class. Over 54% of the sample had high school education while 45% had college education.
Level of education and SES were found to be strongly associated.
17
Burden, Cause and Cost of Caesarian Sections
Thirty four percent of the deliveries were C-section and 65% were normal deliveries. There
was a variation of 10-15% from the mean (39.2% in Thiruvananthapuram and 29.4% in
Kozhikode) in the proportion of C-sections across cities. However, the sample size was not
estimated with inter-city comparisons in mind. Going by age groups, chances for C-section
seem to be high in < 20, 26-30 and > 31 age groups. The proportion of women delivering by
C-section also increased steadily with the socio-economic status. Similarly, the incidence of
C-section increased with the educational status.
Majority of the subjects were primiparas with 2.15% of the sample coming over para 4 and 8.3%
of para 3. This distribution corresponds to the expected distribution as per SRS data.
When Primiparas alone are considered, the chances of CS are significantly high in the age
group above 30 (Chi Square for linear trend is 6.943; p value: < 0.008; OR for group 4 is 9.45).
Proportion of people utilizing private facilities was 53.3%. As figure-1 shows, 43.2% of deliveries
in the private sector were Caesareans and the difference was significant compared to the
government facilities. C-section rate among private institutions was 51.5% in Thiruvananthapuram,
39.2% in Kochi and 35.9% in Kozhikode. It was clear from the study that the private sector cost
much more than the public sector for both types of deliveries. A normal delivery cost 2.39 times
more in private sector while a caesarean cost 2.62 times more.
Fig. 1. Percentage and type of deliveries in different type of institutions
Type of Deliveries
|
■ Normal
■Cesarean
|
While 60.2% of normal deliveries occurred during 12 hours between 5:00 a.m. and 5 p.m.,
79% of C-section took place during 5 p.m. and 5 a.m. The subjects were not given a choice
to decide and the doctor took the decision in favour of C-section. Earlier international studies
indicated that the elective C-section is more in the upper SES but it was not found in this
study. The vast majority (87.2%) of subjects preferred a normal delivery if given a choice
because they felt it was the natural and safe method to deliver.
18
Working Paper Series - 2
Reasons or indications prompting the C-section were more or less the same as those given
out by standard Obstetrics textbooks. Almost all women who had a C-section earlier said
that this time it was an elective procedure. Only one had a normal delivery, she was also
told that she would need surgery but she delivered prematurely. There was no significant
association between the sex of the baby and mode of delivery with the percentage of both
types of deliveries more or less equal in either sex (Chi square p value:0. 734). An increase
in birth weight increase meant a definite and significant increase in the chance for a Caesarean
from 21% in group-1 (babies below 2500g) to 45.5% in group-4 (babies above 3500g). There
was no significant association between mode of delivery and
maternal height (Chi
square p value : 0. 739). The period of admission prior to delivery did not have an effect on
the mode of delivery. However, there was a significant association between the mode of
delivery and the number of days of hospitalisation after delivery. The days of hospitalisation
after a CS were higher than that of a normal delivery.
While 24.6% of the subjects who had a normal delivery took rest for about 90 days, 48.5% of
those who had a CS took this long to return to their routine activities. The mean period of rest
after a normal delivery was 56.6 ± 24.4 and that of CS was 69.5 ± 25.6. Those who had a CS
had a significantly higher chance of taking more days of bed rest after delivery than those
who had a normal delivery.
Only 12 women (3.3%) had less than 5 antenatal visits during the course of the pregnancy.
Average number of antenatal visits was 8.87 (± 2.98). Average number of ultrasound scans
during the antenatal period was 1.183 (± 0.8) and Thiruvananthapuram had a higher mean
compared to the other two. A qualified doctor attended to 99.5% of all deliveries and of
this, an Obstetrician attended 86.5% deliveries! There was definitely an association with
the person attending delivery and type of delivery; those attended to by an Obstetrician
had significantly higher chance of having a CS.
A significantly larger proportion of babies delivered by CS were not breast fed in the first hour
after delivery, than babies who were delivered by CS. Yet, there was no change in infant
morbidity patterns by the mode of delivery (Chi Square p value: 0.517). As for the safety of
their babies, 4 subjects who preferred normal delivery for their own safety thought that a CS
is better for the baby as it does not have to suffer the strain of passing through the birth
process.
Multiple Logistic Regressions
A logistic regression model was used to study the relationships between the individual
independent variables like age, SES, place of delivery, birth weight, number of USS etc and
19
Burden. Cause and Cost of Caesarian Sections
C-sections while controlling for the effects of other maternal and institutional factors. From
the table-2, it is clear that, when adjusted for other factors, the incidence of Caesarean
Sections was significantly related to birth weight (Odds Ratio for the above 3500g group:
3.807; 95% Cl: 1.3 -11.4), time of delivery (the time slot of 5 pm to 5 am being significantly
associated with less number of Caesarean Sections) and the number of USS performed
during the antenatal period (Odds Ratio for the above 3 USS group: 19.5; 95% Cl: 4.9 77.1). The other variables, which were found to be significant on bivariate analysis, did not
return similar results on multivariate analysis.
Table-2. Results of Multivariate Analysis
Variable Odds Ratio
Odds Ratio
95% Cl for adds Ratio
Age Group
20 and below *
21 to 25
26 and above
1
0. 733
1.538
0.301 - 1.785
0.643 - 3.680
Birth Weight
Less than 2500g *
2500 to 3000g
3000 to 3500g
Above 3500g
1
2. 995
2. 911
3. 807
1.297 - 6.916
1.170- 7.241
1.270 - 11.412
Place of Delivery
Government Hospital *
Private Hospital
Govt. Med. College
1
1.551
0.963
0.783- 3.073
0.427- 2.174
Socioeconomic Class
Lower *1
Middle
Uppe
1.250
0. 835
0.668- 2.337
0.321 - 2.168
Time of Delivery
05. 01 am to 05.00 pm *
05. 01 pm to 05.00 am
0.219
1
0.107 - 0.641
Ultra sound scans
No USS *
1 USS
2 USS
3 and above
1
1.462
1.839
19.502
0.692- 3.086
0.777- 4.352
4.934 - 77.084
* Referral Class
20
Working Paper Series - 2
DISCUSSION
Caesarean rate in three Kerala cities was found to be 34.4%. This is higher than the rates
revealed by earlier studies. The KSSP study indicated a rising trend from 11.9% in 1987 to
21.4% in 1996.314 Although the study design does not allow for comparison across cities, it
should, however, be mentioned here that there was a wide variation in the CS rates across
the cities with Thiruvananthapuram recording the highest of 40%, Kochi 35% and Kozhikode
29%. A closer look into the details behind this wide variation calls for a more detailed, thorough
anthropological and sociological study.
There were only two instrumental deliveries out of 360. These were reported cases not
based on hospital records. The subjects may not have been aware of the use of vacuum
extractors as attending physicians seldom mention this later to the patient. Two leading
Obstetricians (one each from private and Government sectors) admitted that the proportion
of instrumental deliveries have indeed declined and claimed that newer crop of obstetricians
(including the respondents) seldom use forceps. Senior staff nurses in the Government
Medical College too said that none of the younger doctors use the method anymore, though
they are trained in their use during their post graduation. Such doctors, when employed in
government or private sector, may lack the confidence to go in for a delivery that may not
be very smooth and opt for a C-Section instead. Declining skills in instrumental delivery
has been suggested as one of the reasons for the rising CS rate.19'14
All of the 360 subjects delivered in a health facility (two deliveries took place outside health
facility - one on the way to the hospital and the other delivered prematurely but immediately
taken to the hospital to complete the third stage of labour). Institutional delivery is, of course,
a pre-requisite for a C-section and we have seen that the CS rate increased with the increase
in the proportion of institutional deliveries.
It was found that 53.3% of our subjects delivered in a private facility. This falls short of the
figure (60%) indicated by an earlier study4. This could be due to the peculiar feature that the
private sector in Kerala is stronger in rural areas than in urban areas. We can hardly find a
village in Kerala where there is no private institution offering obstetric care.
In the private institutions, 42.7% of all deliveries were by CS, while in government institutions,
the figure was 25%. There is a significant association in the place of delivery and the mode
of delivery (c2 p value: < 0.001). This finding is in tune with earlier studies on the matter.4 ’644
Physician convenience, lack of support and monitoring facilities are the reasons quoted for
increased CS rates in the private sector.2' Pahari et al also cited similar reasons for the
21
he-’co
U888G
P':?-
Burden, Cause and Cost of Caesarian Sections
private physicians going in for emergency caesareans rather than a trial of labour. There
was a wide variation in the private sector CS rate across cities, with Thiruvananthapuram
leading the way once again with 51.5%; it was 39.2% in Kochi and 35.9% in Kozhikode.
There was a significant relationship between the time of delivery and the mode of delivery.
Nearly 80% of C-sections took place during 12 hours starting at 5.00 a.m. While 40%
of
the
normal
deliveries took place in the twelve hours between 17.00 hours and
5.00 hours, only about 20% of the CS took place during the same period. Even when adjusted
for other factors like age, place of delivery, SES etc, there was a significant association
between the type of delivery and the time. Deliveries taking place during 12 hours starting
from 5 a.m. had definitely higher odds of being a Caesarean section (Odds Ratio: 2.66).
As cited elsewhere, if majority of the CS were emergency procedures, then we would
expect them to be more uniformly spread out and would not expect such a low figure during
night hours. That the total delivery itself is less in night does not hold much value as 40%
of the normal deliveries take place at night in spite of the fact that all active induction
procedures are usually stopped during night, again because of ‘physician factors' rather
than any scientific reasoning. ‘Physician factors’ include the tendency to avoid work during
inconvenient hours and finish the job in a planned manner rather than waiting expectantly
for the normal
procedure21.
Deliveries
that are quoted as ‘normal’ were far from
being normal, as it is probably the result of a number of other interventions like artificial
rupture of membranes (ARM), priming of the cervix using prostaglandin, induction of labour
using hormones like Oxytocin and epidural anaesthesia
to
name
a few. Now,
even in a normal delivery, according to obstetricians, a convenient and auspicious date is
chosen. These inductions measures are usually started early in the morning so as to
complete the procedure before the day ends. Usually, if the labour is not progressing on
expected lines, the CS surgery takes place in the evening. One of the reasons often mentioned
by the private Obstetricians during key-informant interviews is the
unavailability
of
anaesthetists during odd hours of the night. ‘Physician factors’ mentioned earlier may be in
play here too.
If we used a hypothetical model where all deliveries took place at night, the percentage of
CS would then drop to 10.5%, which may be closer to the actually indicated proportion of CS.
In such a scenario, we would be avoiding 69.4% of the Caesareans that are taking place
now. The rate is much lower than the 15% that the WHO has put forward. The savings in
terms of the direct and indirect costs involved will be huge.
22
Working Paper Series - 2
More than 62% of the Caesareans were emergency procedures, as reported by the mothers.
They meant that they or their relatives were told of the necessity of the procedure only
immediately prior to the surgery. In all cases the decision for CS was the doctor’s alone, and
the subject or relatives did not have any say on the matter. This finding again do not conform
to other studies on the issue which says that ‘patients demand’ constituted the third
commonest reason for CS in the UK in 1992.45 Mello e Souza46 in 1994 quoted the need to
avoid labour pain and the belief that a vaginal delivery would spoil a woman’s future sexual
performance and her husband's pleasure as the reasons for an increased‘patients demand’
for CS. In India, subjects or relatives demanded CS, for the baby to be born on an astrologically
auspicious day.43 If, as suggested by the University Grants Commission, Universities start
Astrology courses across the nation, and it gains more respectability as a science, probably
this trend would rise. But here in our case, with the decision resting entirely on the physician,
these issues do not come into the picture at all.
The indications quoted for CS were more or less in conformity with the classical indications
given in most standard textbooks of Obstetrics. The expected proportions varied from the
observed, but here there is one point which should be kept in mind, that these figures refer to
reported figures and no attempt was made to verify the claims by cross checking with medical
records.
Maternal age is acknowledged as one of the determinants of CS. Women below 18 years
and above 35 years are said to be at high risk for pregnancy related complications and CS.
4748 The findings here suggest that below 20 years and above 25 years had a higher risk (r2
p < 0.004) of C-section. When primiparas alone are considered, there is a very high risk of
CS in the age group of above 30 (r2 for trend: 6.943; p = 0.008; OR for > 30 years: 9.45). This
finding is in tandem with the view of standard textbooks, that the older aged the primiparas,
the higher the risk of a CS. However books define elderly primiparas as those aged above
35 years.
Socio-economic status has been associated with higher CS rates.36 In many Latin American
Countries, a positive correlation has been found between CS rates and per capita GNP.
Christine Nuttall (1999) claims that Caesarean delivery has become a ‘status symbol' among
affluent Brazilian women. Ethnographic studies have also supported this view. Pai (2000)2’
states that this could be one of the reasons for an impossibly high CS rate of 45% in an
urban, upper class society of Chennai. In our study we find that the CS rates steadily increasing
as we go up the socio-economic hierarchy.
23
Burden. Cause and Cost of Caesarian Sections
Similarly, there are many studies which link high educational status to high CS rates.11 30
There are many reasons quoted for this association. One could be that the highly educated
women postpone their first pregnancy, and are thus more likely to have a Caesarean
delivery.'2 Or it could give the women a say in the final decision making which could be one
of the reasons for the high CS rates. We found a similar pattern in our study too, that of the
CS rate climbing steeply with the increase in educational level. The educational status and
the socio-economic status were closely interlinked. So also was the educational status of
the husbands.
Previous CS has been quoted in textbooks as well as studies as a major indication for
CS. However, the American College of Obstetricians and Gynaecologists (ACOG) have
made their policy clear and advice that the routine repeat Caesarean be replaced by a specific
indication for surgery.17 In this study we found that the old dictum ‘once a Caesarean, always
Caesarean!’ seems to be held at high esteem, for of the 43 women who had a previous
Caesarean, 42 had a repeat surgery. Interestingly, the 43™ was told earlier that she would
need surgery, but she defied the dictum to deliver prematurely through the vaginal route!
NFHS-2 stated that women receiving more than 4 antenatal visits were 2 to 4 times more
likely to deliver in an institution.' Institutional delivery brings with it the risk of caesarean too
for ail the reasons cited above. In the Kerala scenario, Institutional delivery is the norm and
almost everyone had at least 5 antenatal visits (only 12 people out of the 360 had less than
5 ANCs) can we expect a high Caesarean rate too?49 The data suggests that the more the
number of ANCs the higher is the chance of Caesarean. As we move up the groups, Group
1 having up to 5 ANCs had a CS rate of 20.4% while in Group 3 having 10 or more ANCs, the
CS rate is 42.9%!
High technology has become a part of everyday life and now here is it more evident than in
the field of medicine. In Kerala, Ultra Sound Scan has become part of the Antenatal Check
up and that too has now become an indicator of one's status in the society. The number of
USS taken by a woman had a profound influence on the type of the delivery. Even when
adjusted for other factors like age and SES, the number of USS did have a significant
association with the type of delivery with the odds ratio going as high as 19.5 for the group
having more than 3 USS. Women who have complications will have more USS and they are
naturally at higher risk of Caesarean. The same could be true for the number of antenatal
visits too, the more the risk of a complication, the more will be the number of antenatal visits
24
Working Paper Series - 2
and more will be the chance of a Caesarean. Another possibility is that the number of antenatal
visits and the number of USS will be higher in the upper SES, and they are naturally at a
higher risk of CS. We found a strong association between SES and the number of antenatal
visits, with over 75% of the upper SES group going for more than 10 antenatal visits. The
association was equally strong in the case of USS too, with a significantly higher proportion
of subjects having had 3 or more USS belonging to the upper SES. Birth weight was one of
the major indications for Caesarean. As birth weight increased from below 2500g to above
3500g, the chance of CS rose from 21% to 45.5%. Even for baby weighing between 2500
and 3000g, the risk of CS was a high 34.3%. This was found to be significant even when
adjusted for other variables found to be significant on bivariate chi-square analysis, with the
odds ratio steadily increasing as we go upwards from the above 2500 group onwards (from
2.9 in the 2500 - 3000g group to 3.8 in the above 3500g group). This was not at all in
accordance with findings of separate surveys conducted among Obstetricians in London
and in twelve states of USA and territories of Canada where 39% preferred CS if the baby
was estimated to be above 4500g . CS rates were found to be higher for babies with over
3000g in many other studies too.'0- ,2Standard textbooks offer a limit of 4500g above which
they recommend a Caesarean section. As mentioned earlier, ‘physician factors’ play an
important role here. When the doctor sees a full-term pregnant lady armed with one or more
USS reports saying that the weight of the baby is likely to be on the higher side, he/she likes
to play safe and go in for a CS than take a chance with a difficult normal delivery. So, babies
with a weight of above 3500g who could easily be born normally, now ends up being delivered
through a CS.
Maternal Height is an important indicator of the type of delivery. Short-stature Primi gravidas
are prime candidates for Caesarean Sections. Many traditional text books on Obstetrics
state that women below 135 cm are likely to have a CS. Our data however did not return any
significant relation between maternal height and mode of delivery. Probably it is because
our sample had only 8 women below 140 cm. It may also mean that there is no real relation
between the expected indications for a CS and the actually observed ones!
From our data, we find that the risk of CS is greater if attended to by an Obstetrician than
a GP. Once again, the explanation could be quite straight forward, a trained expert obstetrician
is more likely to be employed in a major centre with all the facilities and modern gadgetry,
while a general practitioner is more likely to be employed in a small scale setup where he has
25
Burden. Cause and Cost of Caesarian Sections
to make do with makeshift facilities. A high risk pregnancy is likely to be referred to a major
centre and thus the chances for a CS is much more because of the better equipped health
facility and may not be because of the obstetrician working there. Lack of trained and
experienced midwives, who could take away a substantial workload from the physician,
could be one of the reasons for the rising CS rates.,9-'4 In Netherlands, the midwives play an
important role and conduct a good proportion of the deliveries at home. The CS rate for
Netherlands (10%) is one of the lowest in Europe.20
Hospital stay was significantly high for the CS subjects. While 90% of those who had a
normal delivery left the hospital within 6 days, 82.7% of the CS women left the hospital
after 7 days. This could have a great impact on the total cost also apart from the prolonged
morbidity that befalls the woman who undergoes a Caesarean. Similarly, women who had a
CS took longer to return to their routine activities.
Early initiation of breastfeeding has an important role in reducing maternal and infant/chiid
mortality. The Baby Friendly Hospitals Initiative (BFHI) launched by the UNICEF, recommends
initiation of breastfeeding as soon as the cord is cut. One major drawback of CS is that
breastfeeding is delayed and this can cause problems to the mother and the child. While
only 4.2% of the babies born normally were not put to breast by the end of 2 hours, 45.2% of
the babies born by CS were not put to breast even at the end of 2 hour. There was no change
in the pattern of infant morbidity in the first two months with the mode of delivery.
If given a choice, 87.2% of the subjects preferred vaginal delivery for their safety. The
reasons they gave were that it was the natural and safe method to deliver. Many even
expressed apprehensions about the safety Caesarean Section. 12.8% of the women felt
that CS was safe and painless and they would prefer to deliver that way if given a chance.
With more and more women preferring to deliver through a CS, our CS rates will go through
the roof. If the baby’s safety was the prime consideration, 4 of those who preferred a normal
delivery for themselves, felt that a CS is better for the baby as it is spared of the strain it has
to undergo in the normal process. One mother thought that it would be difficult to care for the
baby if she had to undergo a CS. These findings are totally opposed to the providers' claim
that they were under extreme pressure from the patients and their relatives to perform a CS
even when they were certain that it was not absolutely necessary.50
Finally, coming to the cost, we could only crudely estimate the direct cost of the delivery. As
the reference period was one year, most of the women could not recall the exact amount
26
Working Paper Series - 2
paid for each category in calculating the exact cost. However, they knew the amount of the
final bill of the hospital and this was the only figure we could capture in our study. In the
process of the study, we contacted 12 private hospitals (4 in Thiruvananthapuram, 5 in Kochi
and 3 in Kozhikode) and crosschecked the figures and it was found to exact in 96% of the
cases. The same could not be done in Government facilities, as it involved hidden costs like
the fee paid to the doctor and other categories of staff.
The mean cost of a normal delivery in a Government facility was Rs. 1907 ± 1429 and in
the private facility, Rs. 4559 ± 2336. For a Caesarean, the mean in a Public Facility was
Rs. 4044 ±1917 and in a private hospital, Rs. 10613 ± 3238. The difference in cost of a
CS and a normal delivery in a public facility is Rs. 2137 while in a private hospital it is
Rs. 6054. If we take 15% CS as set by the WHO as the limit and consider the difference
between the observed rate and this as excess, we could see that 5326 caesareans are
taking place every year in these three cities, in excess of the acceptable limit. From the data
we know that 66.9% of these are likely to take place in private hospitals and the rest in public
hospitals. So, it is estimated that, the public spends Rs. 2,53,37,488/- extra every year on
unjustified interventions. The total extra expenditure could be much more as we should add
the amount spent each year by the Government on providing these obstetric services to this
figure.
Strengths and Weaknesses of the study
The major plus point of the study was its community-based structure. Earlier studies, which
looked into this area, were mostly based on secondary data. Cluster sampling technique
made use of in this study did provide a representative cross section of the population.
We could not crosscheck the authenticity of the indications of CS from hospital records
and so there are likely to be some margin of error in the reported indications. Another drawback
was that we took only the live births into consideration, as the first question we asked on
entering any house was that if there was a child there below the age of one year. This could
affect the overall rates of normal and CS deliveries. As the recall period was one year, the
figures provided in the cost section could be misleading. We could not get data on most of
the queries related to this section, and only the direct cost could be estimated to a verifiable
extent. It was one of our major objectives but as we were seriously curtailed by non-availability
of data, analysis and projections had to be made from the available figures on direct costs.
27
Burden, Cause and Cost of Caesarian Sections
CONCLUSIONS
C-section rate in the three cities of Kerala was 34.4%, more than double that of the desirable
standards set by the WHO. This is despite more number of antenatal visits. This gives
credence to the viewpoint that more antenatal visits and 100% institutional deliveries do not
guarantee that the best care is being given. More revealing is the abysmally low rate of
instrumental deliveries, 2 in 360 deliveries. We should accept the fact that, through
decades, our over-emphasis on better antenatal, perinatal and post natal care have led to
the ‘medicalization’ of an otherwise normal, physiological phenomenon. We should also
remember that Kerala is standing now where most of the developed countries stood years
back. They had the political will and determination to see that such unwanted and harmful
practices should end and gave right to imaginative and effective strategies, which did succeed
in bringing down the inflated rates.
Policy Implications and Recommendations
Caesarean Section is a major abdominal surgery, which could be life saving for the mother
and the baby. But the fact that it carries with it documented medical risks like infections,
haemorrhage, transfusion complications, injuries to other organs, anaesthesia complications
and even an increased risk of maternal mortality by four times should not seen lightly. An
elective CS increases the risk of the infant of premature birth and respiratory distress
syndrome, both of which are associated with multiple complications, intensive care and
burdensome financial costs. Even for mature babies CS could lead to breathing difficulties.
It can further delay maternal-child interaction and breast-feeding.
Estimation of the CS rate is only the first step towards the ultimate goal of regulation
of unnecessary surgical interventions. Formulating regulations alone may not be effective.
It is important to make the medical fraternity aware of the situation and ask them to come
forward with new ideas. The need for regulation should come from within. And for that, more
studies of this nature are required. Indian Medical Association, a non-political umbrella
organization of the doctors working in all sectors, can and should take the lead here.
28
Working Paper Series - 2
Another potential area where some sort of regulations can be brought in is by the Institutions
themselves. There have been such initiatives in the past in the developed countries,
which have worked admirably. The Mount Sinai Caesarean Reduction programme is one
such example, which effectively brought down and sustained the CS rates. Each institution
offering obstetric care should set up audit systems. The government can formulate institutional
guidelines.
Another area where we need a lot of input is in creating proper awareness of the actual
indications, its advantages and health consequences of Caesarean Sections. Misconceptions
need to be addressed through a well thought out and implemented awareness generation
drive involving all strata of the society.
ACKNOWLEDGEMENTS
This work would not have materialized without the whole-hearted help of some individuals,
those intellectual, physical and emotional contributions are gratefully acknowledged here.
The idea was the brainchild of Dr. K. R. Thankappan, my guide. I am proud to have been
associated with him and I thank him with all my heart for all the help and advice. My co-guide
Dr. Varatharajan was a constant source of inspiration and he is the one, who fine-tuned it to
this shape. I express my sincere gratitude to the 'economist who speaks plain English’.
Dr. Sankara Sarma helped me unravel the mysteries of analysis. Dr. Mala Ramanathan,
who already has done a lot of work in the area, helped me immensely to formulate the
questionnaire and also during my search for literature. I gratefully bow my head before these
two wonderful persons.
I gratefully acknowledge the contributions made by Dr. T.K. Sundari Ravindran,
Dr. Jayaprakash Muliyil and Dr. Madhukar Pai during the course of this study.
And I hope I can reciprocate the feelings in the same magnitude for the love and support
shown by my wife, Molly, and my kids Revu and Rohit.
29
Burden, Cause and Cost of Caesarian Sections
REFERENCES
1.
NFHS 2001. National Family Health Survey India 1998-99. Mumbai: International Institute for
Population Sciences.
2.
Sample Registration System 2000. SRS is published by the office of the registrar general India.
33(1)3.
3.
Aravindan KP and Kunhikannan TP (2000). Health Transition in Kerala. Kerala Sasthra Sahitya
Panshad, Parishad Bhavan, Kozhikode
4.
Homan R K, Thankappan K R (1996). Patient Reports on Hospital Care in Trivandrum District,
Kerala, India: Public vs. Private Sector, Proceedings of Association for Health Services Research
(AHSR). 13"' Annual Meeting in Atlanta Georgia, USA.
5.
Sabu S. Padmadas, Suresh Kumar S, Sajini B. Nair and Anitha Kumari K R (2000). Caesarean
Section delivery in Kerala, India : evidence from a National Family Health Survey. Social
Science and Medicine 2000;51:511 -521
6.
Undergraduate project (PSBH) (2000). Caesarean Sections; The Real Picture (Unpublished).
Dept, of Community Medicine, Medical College, Thiruvananthapuram.
7.
Kimberly D. Gregory, Sally C. Curtin, Selma M. Taffel & Francis C. Notzon (1998). Changes
in indications for Caesarean delivery: United States 1985-1994, Am J Public Health 1998:88:1384-
1387
8.
Therese Southgate M. Caesarean Section. JAMA 1985;253:811-818
9.
Rosenthal AN, Paterson-Brown S. Is there an incremental rise in the risk of obstetric intervention
with increasing maternal age? Br J Obstet Gynaecol 1998;105(10):1064-1069
10.
Webster LA, Daling JR, McFarlane C, Ashley D, Warren CW. Prevalence and determinants
of caesarean section in Jamaica. J Biosoc Sci 1992;24(4):515-525
11.
Chacham AS, Perpetuo IHO. The incidence of Caesarean deliveries in Belo Horizonte,
Brazil ; social and economic determinants. Reproductive Health Matters 1998;6:115-121
12.
Parazzine Fetal, Determinants of Caesarean rates in Italy. Br J Obstet Gynaeco 1992;199:203-206
13.
Savage W. Caesarean Section in Britain and the United States 12% or 24%: is either the right
rate? Social Science & Medicine 1993;37:1199-1218
14.
15.
Savage W. Caesarean sections on the rise. Natl Med J India 1999;12(4): 146-149
Gregory L. Goyert, Sidney F. Bottoms, Marjorie C. Treadwell and Paul C. Nehra. The Physician
Factor in Caesarean Birth Rates. N Engl J Med 1989;320:706-709
16.
Haynes de Regt R, Minkoff HL, Feldman J, Schwartz RH. Relation of private or clinical care
to the caesarean birth rate. N Engl J Med 1986;315(10):619-624
30
Working Paper Series - 2
17.
International Caesarean Awareness Network (2000). ICAN Website http://www.childbirth.org
18.
Lancet Editorial. What is the right number of Caesarean Sections?
19.
Faundes A, Guarisi T, Pinto-Neto AM. The risk of urinary incontinence of parous women
who delivered only by Caesarean section. Int J Gynaecol Obstet 2001;72(1):41-46
20.
Treffers PE, Eskes M, Kleiverda G, van Alten D. Home births and
interventions. JAMA 1990;17:2203-2208
21.
Pai, Madhukar. Unnecessary Medical Interventions: Caesarean Sections as a case study. Econ
Pol W.
22.
Petitti DB. Maternal mortality and morbidity in Caesarean section. Clinical Obstet Gynecol
1985;28(4):763-769
23.
Mukherji J and Samaddar JC. How safe is Caesarean Section? J Obstet Gynaecol 1995;21:17-21
24.
Boehm PH, Davidson KK, Barrett JM.The effect of electronic fetal monitoring on the incidence
of Caesarean section. Am J Obstet Gynecol 1994:140(3):295-298
25.
Sehgal NN. Changing rates and indications of Caesarean Sections at a community
hospital from 1972 to 1979. J Community Health 1981;7:33-46
26.
Bhargava A. HIV disease in Kheda district. Medico Friend Circle Bulletin 1998;250/251:12-15,
Social Science & Medicine 1998; 37:1219-1222
27.
Kamal P, Wadia BJ. Caesarean Hysterectomy on the rise: a consequence of increased rate of
CS. J Obstet Gynaecol of India 1994; 889-893
28.
Pai M, Sundaram P, Radhakrishnan KK, Thomas K & Muliyil JP. A high rate of CS in an affluent
section of Chennai: Is it a cause for concern? Natl Med J India 1999;12:156-158
29.
DiMatteo MR, Morton SC, Lepper HS, Damush TM, Carney MF, Pearson M. Caesarean
childbirth and psychosocial outcomes: a Meta analysis. Health Psychol 1996;15:303-314
30.
Cynthia S. Mutryn. Psychosocial impact of Caesarean section on the family: a literature review.
Social Science & Medicine 1993;37:1271-1281
31.
Oakley A. Social consequences of obstetric technology: the importance of measuring "soft"
outcomes birth. Summer 1983;10(2):99-108 (No abstract available).
32.
Lancet 1997;349:815
minimal medical
Kannan KP, Thankappan KR, Kutty VR and Aravindan KP. Health and development in rural
Kerala. Kerala Sastra Sahithya Parishad 1991, Trivandrum.
33.
Stephen A Myers and Norbert Gleicher. The Mount Sinai Caesarean Reduction program: an
update after 6 years. Social Science & Medicine 1993; 37:1219-1222
31
08866
f7®25
Burden, Cause and Cost of Caesarian Sections
34.
Francis C Notzon, Paul J. Placek & Selma M.TaffeL (1987) Comparisons of National CaesareanSection rates. N Engl J Med 1987;316:386-389
35.
Selma MTaffel, Paul J. Placek, Mary Moien. US Caesarean rates at 24.7 per 100 births - A
plateau? (Letter to the Editor). N Engl J Med 1988;323:199-200
36.
Belizan JM et al. Caesarean Section and fear of litigation. Lancet 1991; 338:1462
37.
Murray SF, Serani Pradenas F. Caesarean birth trends in Chile, 1986 to 1994. Birth
1997;24(4):258-263
38.
Cai WW, Marks JS, Chen CH, Zhuang YX, Morris L, Harris JR. Increased Caesarean section
rates and emerging patterns of health insurance in Shanghai, China. Am J Public Health
1998;88(5):777-780
39.
Studnicki J, Remmel R, Campbell R, Werner DC. The impact of legislatively imposed practice
guidelines on Caesarean Section rates: The Florida experience. Am J Med Qua! 1997;12:62-68
40.
Lomas J, Enkm M, Anderson GM, Hannah WJ, Vayda E, Singer J. Opinion leaders vs audit and
feedback to implement practice guidelines. Delivery after previous Caesarean section. JAMA
1991; 265(17):2202-2207
41.
Socol ML Peaceman AM. Active management of labor. Obstet Gynecol Clin North Am
1999;26(2):287-94. Review.
42.
Rogers R, Gilson GJ, Miller AC, Izquierdo LE, Curet LB, Qualls CR(1997). Active management
of labor: does it make a difference? Am J Obstet Gynecol 1997;177:599-605
43.
KabraSG, R. Narayanan, M. Chaturvedi, P. Anand & G. Mathur. What is happening to Caesarean
section rates? Lancet 1997;343:179-180
44.
Randall S. Stafford. The Impact of Non-clinical Factors on repeat Caesarean Section. JAMA
1991; 265:59-63
45.
Atiba EO et al. Patients’ expectations and Caesarean section rates. Lancet 1993;341:246
46.
Mello e Souza. C-sections as ideal births: the cultural constructions as of beneficence and
patients rights in Brazil. Cambridge Quarterly of Health Care Ethics 1994;3:358-366
47.
Hobcraft JN, JW McDonald and SO Rutstein. Socio-economic factors in infant and child mortality:
a cross-national comparison. Population Studies 1984; XXXVIII (2):193-223
48.
49.
Bottoms SF et al. The increase in Caesarean birth rate. Medical Intelligence 1980; 302 (10):559-565
Mishra US and Mala Ramanathan. Delivery Complications and Determinants of Caesarean
Section Rates in India - An Analysis of National Family Health Surveys, 1992-93. Working
paper No. 314 2001, Centre for Development Studies, Thiruvananthapuram.
50.
Hopkins,
Kristine. Are
Brazilian women really choosing to deliver by caesarean? Social
Science and Medicine 2000;51 (5):725 -740
32
WORKING PAPER SERIES
There are ample opportunities for the AMCHSS students to indulge in advanced,
well-diversified and inter-disciplinary research as the theoretical course modules
and in-class trainings are designed to equip them with various methodologies
concerning the disciplines of anthropology, economics, epidemiology, environment.
gender, management, policy and statistics. The faculty members add further depth
and variety to the centre’s research capability. The potential for research gathered
further momentum from the year 2003 when the centre started Ph.D. programme in
public health. On the whole. AMCHSS is generating considerable research on a
regular basis and on a variety of topics related to public health.
The centre would like to sharpen its research potential further by enlightening the
researcher with the methodological insights, theoretical novelties and expert
commentaries on government policy measures thrown open by the scholars from
across the globe. Keeping this in mind, it was proposed to start a working paper
scries in public health from January 2001. The series objectives are :
o
To throw light on contemporary policy challenges in the field of public health;
o
To disseminate the research findings of completed studies;
o
To deliberate the preliminary results of on-going studies and
o
To share new research ideas, recent theoretical developments, and fresh
methodological insights.
Learned professors and high-level experts from internationally renowned institutions
and universities in India and abroad are invited to contribute to the series. Besides.
top two ranked MPH dissertations and papers by the faculty members are also
published. Hence, the working paper series would provide an opportunity for the
students, researchers and policy makers in the neighbourhood as well as from beyond
the boundaries of the city, stale and the country to equip themselves with the latest
research works of the reputed scholars in the field of public health and allied
disciplines. The present paper, “Burden, cause and cost of cesarean sections: a
community based study in the three city corporations of Tliiruvananthapuram. Kochi
and Kozhikode. Kerala" by Dr. K. Hemachandran. his MPH dissertation, is the second
working paper in the series.
Scries Editors
ACHUTHA MENON CENTRE FOR
HEALTH SCIENCE STUDIES
The Achutha Menon Centre for Health Science Studies (AMCHSS) is the Health
Sciences wing of the Sree China Tirunal Institute for Medical Sciences & Technology
(SCTLMST). The main objective the AMCHSS is to train health professionals in health
research and in formulation and implementation of health policies. It comprises of
core and visiting faculty in Anthropological Perspectives of Health. Biostatistics.
Epidemiology. Environment & Occupational Health. Field Study in Public Health,
Gender Issues in Health. Health & Development. Health Economics. Health Management
and Health Policy analysis. It’s panel of visiting faculty includes experts from All India
Institute of Medical Sciences (New Delhi). Centre for Economic and social studies
(Hyderabad). Christian Medical College (Vellore). Centre for Development Studies
(Thiruvananthapuram), Harvard School of Public Health (USA). Johns Hopkins
University (USA). Tala Institute of Social Sciences (Mumbai). The World Health
Organization (New Delhi). The World Bank (New Delhi). University of Arizona
(USA), University of Auckland (New Zealand). University of California LA (USA).
University of Sussex (UK) and University of Zimbabwe (Zimbabwe).
The AMCHSS offers an international Master of Public Health (MPH) programme.
shon courses and Ph.D. programme catering to all South Asian countries. The
Ministry of Health and Family Welfare. Government of India recognized the AMCHSS
as a ‘centre of excellence' for public health training and sponsors candidates for the
MPH under the WHO Fellowship Programme. Besides, AMCHSS is the Secretariat
for the Public Health Schools without Walls Network, a network of Public Health Schools
in Asia and Africa.
In short span of five years, the members of the AMCHSS have authored 8 books, 31
research papers in national & international journals. 9 research articles and 7 chapters
in books. The AMCHSS has already completed or is conducting work on 15 projects
attracting financial support from the Centre for Development Studies. CHANGE
(Washington DC). European Commission (though Government of Kerala). Ford
Foundation. Government of Kerala. Health Policy Development Network
(HELPONET). MacArthur Foundation, Rockefeller Foundation and the World Health
Organisation.
Dr. K. R. Thankappan
Acting Head
Position: 1272 (4 views)