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Complications, Safety and Caesarian section rates

“There is no convincing and compelling evidence that hospitals give a better guarantee of safety for the majority of mothers and babies…The policy of encouraging all women to give birth in hospitals cannot be justified on grounds of safety.” United Kingdom House of Commons’ Report on Maternity Services (Winterton Report, 1992)

People usually think of traditional practitioners and practices as unsafe—but we must remember that dais serve the poorest of the poor—women whose health status is already compromised when they conceive. Often they are overworked, malnourished, live in degraded environments, drink polluted water, are victims of gender violence and have no access to medical care. Are the dai or her practices responsible for maternal-child health problems within this environment? Or are the conditions of poverty responsible?

Every midwife, anywhere in the world, wants medical backup for emergencies—dais and the women they serve want the same. Skilled doctors and well-equipped hospitals and nursing homes can be life-saving in an emergency. The problem, for the majority of poor women in India is that a doctor can do no more in a hut in a rural area with a birth crisis (and often less!) than can an expert dai. Doctors need an operating theatre (with electricity) and anaesthetist and pharmaceuticals, a blood bank, and all the paraphernalia of modern obstetrics to make a life-saving difference. As much as we might like to have these available for all birthing women, we currently do not. So a policy of institutionalized birth for all women is counter-productive.

Safe Motherhood—Bureaucracies and Babies

An increasingly influential lobby is the Safe Motherhood movement—they follow the global refrain of the World Health Organization and Unicef “Skilled Attendance at Birth.” This skilled attendant is defined as a practitioner able to use pharmaceuticals during a birth emergency. However they do not consider dais as skilled nor are the majority of them considered able to become skilled. Why? Because they are not literate or able to use pharmaceuticals. The problem is one of human resources—how to utilize local, indigenous personnel for the majority of births and commit to provide facilities (well staffed hospitals and transport) for emergency situations.

According to a prominent obstetrician representing the Federation of Obstetricians and Gynecologists at a Safe Motherhood meeting

“There are 1700 obstetrical and gynecological positions lying vacant in government clinics in India. Part of the reason is that most obstetricians are women, and women don’t go out to rural areas and staff Primary Health Centres and First Referral Units.”

Most research shows that poor and traditionally oriented women want to give birth at home. The task of appreciating the skills of indigenous practitioners and practices in the area of obstetrics has not been attempted—in part because the bio-medical orientation of caregivers and policymakers. It is questionable how the right to Safe Motherhood might be realized when there is no right to work, right to food, or the right to use indigenous practitioners along with modern medical facilities? Safe motherhood advocates graphically showcase the suffering and deaths of poor women during childbearing. But women don’t suffer and die simply because they are pregnant, but because they are impoverished, malnourished and overworked.

The Caesarean Epidemic

(much of the data quoted below is dated. In part this is dure to the fact that the medical establishment dominates research in public health and hesitates to document and advertize its own failings)

On the other hand middle and upper class women face the over- medicalization of birth. One Indian study maintained that current high caesarean rates were part of a rising trend. In the states of Kerala and Goa, as well as Andhra Pradesh, Bihar, Gujarat, Karnataka, Punjab and Uttar Pradesh the risk of undergoing a caesarean section in private sector institutions is four or more times that in the public sector. (US Mishra and Mala Ramanathan “Delivery-related complications and determinants of caesarean section rates in India” Health Policy and Planning; 17 (1) 90-98)

According to one World Health Organization document “Countries with some of the lowest perinatal mortality rates in the world have caesarean rates under 10%. Clearly there is no justification in any specific region to have more than 10-15% caesarean section births."

"Between 1970 and 1988, the American caesarean section rate rose from 5% of all births to nearly 25%. Few experts believe, and none have sound data, that American mothers or infants are on the whole better off because of this change. The occasional reports of complications, from delayed cesarean section, such as uterine rupture or fetal distress, make more headlines than the much more common, but harder-to-assess complications-pain, anesthesia risks, post-operative infections, and blood loss, for example-from hundreds of thousands of cesarean sections that simply did not need to be done." (National Coalition on Health Care Report .D. B. Berwick)

In Sweden the caesarean section rate declined from 12% in 1983, the highest it had ever reached there, to 10.8% in 1990. At the same time perinatal mortality rates were reduced by half. Nordic countries are the only ones that have succeeded in keeping their caesarean rates from rising and where the rates did not exceed 14% through the 1990s. ( Sheila Kitzinger, The Politics of Birth)

"The lack of concern among many obstetricians about the after-effects of the rising caesarean rates may result from the fact that they spend little time post-natally with women who had had caesarean sections and are far removed from any physical or psychological ill-effects resulting from the operation." ( Francome, C.,Savage, W., Churchill, H. and Lewison, H. 1993. Caesarean Birth in Britain. London: Middlesex University Press.)

Continued increases in rates of obstetrical intervention are unlikely to lead to improvements in birth outcome and may result in a higher incidence of adverse outcome for mothers and their offspring. The risks associated with caesarean section include: damage to uterine blood vessels; accidental extension of the uterine incision; damage to the urinary bladder; anaesthesia accidents; wound infections; maternal mortality. Depressed Apgar score; higher rates of neonatal respiratory distress; shortened mean length gestation; and higher perinatal mortality in subsequent pregnancies." ( World Health Organization, 1992. International Differences in the Use of Obstetrical Interventions)

J. Quilligan, MD, an editor of the American Journal of Obstetrics and Gynecology wrote, "Every hospital that has an obstetric service should have some committee that examines every cesarean section that is performed in that hospital and determines whether it was indicated or not. If it was not indicated, then the physician who performed the section should be educated as to why it was not indicated." ( B.L. Flamm and E.J.Quilligan, Editors. 1995. Cesarean Section: Guidelines for Appropriate Utilization. New York: Springer-Verlag.)

Luella Klein, MD, Past President of the American College of Obstetricians and Gynecologists (ACOG) said, "Reducing cesarean section rates is not easy. It will require a major change in attitudes for patients, for obstetricians, for nurses, for hospitals, and for families... We need to close the gap between what we know to be an appropriate cesarean rate and what is actually done in practice. We could get a health bargain for women and a financial bargain for our health care system." (Flamm, B. L., Kabcenell, A. Berwick, D.M. and Roessner, J. 1997. Reducing Cesarean Section Rates While Maintaining Maternal and Infant Outcomes. Breakthrough Series Guide. Boston: Institute for Healthcare Improvement
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