From His Mother’s Womb Untimely Ripp’d

June 9, 2008

While I’m in favour of Indian newspapers doing more feature stories that go more in-depth than five hundred words and two soundbites, this Mint article on Caesarean sections is not the way to go. It’s poorly researched, inconclusive, meanders all over the place, and does too much New York Times level balancing of opposing opinions, even when the opposing opinions don’t necessarily have equal relevance or weight.

I am an MBA and not an MBBS. Also, I am unlikely to ever receive a C-section (though the possibility can never be ruled out). As both a producer and consumer of C-sections, I lack experience and expertise. However:

  1. I am a smartarse who likes to call out wonky reasoning even when I know nothing about the underlying facts the reasoning is built on.
  2. I also have a personal interest in infants as sacrifices to Elder Gods and a food source.
  3. I was in Section C in IIMB and I feel this obliges me to defend all C-sections. In fact, Kodhi and me wanted to use ‘I was reborn by C Section’ as the class tshirt slogan but Bubbly shot down the idea because she thought it was too gross.
  4. Defending C-sections has the added advantage that it may piss off the Mad Momma.

Right. So here we go. First, the article. As I alluded above, it’s mostly a collection of sound-bites without any solid analysis, and so doesn’t really qualify as good feature journalism. It takes quotes from every possible party concerned, and doesn’t develop any of them. But such is life.

Then there’s confusing correlation and causation:

The burst in numbers is also inextricably linked with the advent of “corporatized” private health care in India.
Birth is big business; delivery rates vary from city to city, but a large private hospital in Delhi can earn up to Rs70,000-80,000 for a Caesarean package (including room and OT charges), whereas a normal delivery package brings in around Rs44,000, according to numbers collected by a team of doctors at Sitaram Bhartia hospital.

Yes, fine, but a Caesarean delivery would cost more than a normal delivery even at a non-corporatised hospital or clinic. The rise of corporatized health care is due to rising affluence and a preference for reliability. The preference for C-sections is also due to rising influence, as the article itself points out:

Urban Indian women are now marrying later, conceiving later in life, and having fewer children. Every child is so precious that parents are averse to taking any risk and are increasingly viewing the Caesarean as a reliable option.

Rather, the growth in C-section numbers, he says, is better explained by changing urban lifestyles, busy obstetrician schedules and the convenience of planned procedures. “Many women try to schedule Caesarean procedures on special days such as birthdays or festivals,” says Barua. On some of these days, women line up for Caesareans,” he adds.

Just because affluence leads to corporate health service, and affluence also leads to a preference for C-sections, doesn’t mean corporate health service leads to C-sections. Or vice versa.

OK, but what about the actual medical risks? Those are important too, right? Well, here the article goes into this, that, but on the other hand again:

There is no denying the fact that Caesarean sections routinely save lives. In the event of certain serious pregnancy-related complications, the surgery can be a mother or baby’s only hope. At least two studies have also shown that scheduled or “elective” C-sections—as opposed to an “emergency” Caesarean section in which a mother or child is already in distress—may even be safer than vaginal deliveries. Some scientists also argue that the procedure can help reduce the risk of problems such as incontinence in later life.

Research, however, challenges these claims, and throws light on the problems that can complicate a surgical birth. Bleeding can be severe and the surgical wound can get infected. Recovery time is weeks longer and more painful. And, after one C-section, a mother faces serious risks during her next delivery, including the chances of uterine rupture or her new baby’s placenta attaching itself to her scar.

So what we have here is a choice of risks, yes? When the mother is in distress, it’s not really a difficult decision – the risk of infection, and of not being able to control bleeding is much more easily dealt with than the risk of something far more complicated like upside-down breech babies (mentioned earlier in the article). But yep, what about next delivery risks? This study conducted in South Australia mentions them. It measures what the odds of particular illnesses or complications in a mother’s second birth are, when the first birth is a C-section. 95% of the time, the increased risk compared to a normal birth are:

  • Head not coming out first: 65% to 106% more likely
  • Placenta previa: 30% to 111% more likely
  • Hemorrhaging: 8% to 41% more likely
  • Placenta accreta: 2.28 to 864 times more likely
  • Prolonged labour: 3.91 to 8.89 times more likely
  • Low birth weight: 14% to 48% more likely
  • Emergency C-section: 8.98 to 9.67 times more likely

Which sounds scary, except for two things. First, the study itself makes a disclaimer: Cesarean delivery is associated with increased risks for adverse obstetric and perinatal outcomes in the subsequent birth. However, some risks may be due to confounding factors related to the indication for the first cesarean. In other words, the first C-section may have been caused by medical factors which also led to increased risks in the second birth. Secondly, the risks are already small: placenta accreta occurs once in every 2500 births. Even if the chance of placenta accreta goes up a 100 times, it’ll only happen 4% of the time. Not vanishingly small odds, but small enough that you can trade-off the increased risks with the comfort and security of a C-section the first time.

What about the study the article mentions? The one about increased risk of respiratory problems?

In a study reported last December in the British Medical Journal, researchers studied 34,458 live births in Denmark—of these, 2,687 were elective Caesareans—and found that C-section babies were up to four times more likely to have respiratory problems.

Here’s a link to the study in question. Elective C-section babies are four times more likely to have respiratory problems. However, when you break down the odds by when the C-section happens – it turns out that while the odds are even higher than four times if the C-section is early – when the C-section happens in the same week the natural birth would have; there is no significant difference in the risks. The study is not an argument against C-sections, but against scheduling early C-sections – which is very sensible.

What really makes me angry in the article is this quote:

“We’ve come to believe that C-sections are safe but it’s an urban myth,” says Ruth Malik, 38, who co-founded Birth India, a natural childbirth advocacy group in Mumbai, last year, after having gone through two Caesarean procedures she now believes weren’t necessary. Ruth, who recently filed a suit against her doctor in Mumbai, says: “Birth is not an illness. We don’t need a surgeon to help us have babies. It’s a natural function, it’s something our bodies simply know how to do.”

OK, safe C-sections being an urban myth is something that makes me want to scream out ‘citation needed’. Safe in what context? How safe or unsafe? Natural birth isn’t 100% safe and neither are C-sections. The question is, are they safe enough? For negligibly less safety, is a lot more convenience worth it? Why not let the mother decide?

The scary thing about the ‘nature never intended this!’ argument against C-sections is that it can go down a slippery slope. If you argue against C-sections because they were never intended by nature, you can also argue against abortions. Or pacemakers or kidney dialysis. In fact, to contact lenses and spectacles.

Readers (especially Ritwik, probably) will now rush in to point out that the slippery slope argument is absurd. There is a ‘yuck’ factor about abdominal incisions that is not there in spectacles. And pacemakers are lifesaving devices while elective C-sections are largely about convenience.

So what? Cosmetic surgery is about convenience and not lifesaving, but there are no advocacy groups against it. So is LASIK surgery for that matter. And what about ear piercing and tattooing? Those are invasive body modifications which are not necessary at all, and also come with risks of infection, but nobody sensible argues against them on the grounds that they’re unnatural. (For more comprehensive and better written articles about biological enhancement, naturalism, and dignity, read this and this)

Yes, it is sensible to make informed choices about whatever you do – take out a home loan, go driving instead of taking a bus, or getting a C-section instead of a natural delivery. But this should be based on the risks to you personally, not vague platitudes about whether it was intended by nature or not. We can trust mothers to make the right decision about whether C-sections suit them or not, without bringing in conspiracy theories about corporate healthcare, or whether caesarean sections are ‘natural’ or not.