Year : 2007 | Volume : 32 | Issue : 3 | Page : 222-224
Bhasin SK, Rajoura OP, Sharma AK, Metha Mukta, Gupta Naveen, Kumar Shishir, Joshi ID
Department of Community Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi - 110 095, India
Date of Submission 22-Jul-2006
Bhasin S K
Department of Community Medicine, University College of Medical Sciences and Guru Teg Bahadur Hospital, Delhi - 110 095
|Source of Support: None, Conflict of Interest: None|
|How to cite this article:
Bhasin SK, Rajoura OP, Sharma AK, Metha M, Gupta N, Kumar S, Joshi ID. A high prevalence of caesarean section rate in East Delhi. Indian J Community Med 2007;32:222-4
|How to cite this URL:
Bhasin SK, Rajoura OP, Sharma AK, Metha M, Gupta N, Kumar S, Joshi ID. A high prevalence of caesarean section rate in East Delhi. Indian J Community Med [serial online] 2007 [cited 2007 Nov 30];32:222-4. Available from: http://www.ijcm.org.in/text.asp?2007/32/3/222/36837
Pregnancy and delivery are considered as normal physiological states in women. Of all deliveries, approximately 10% are considered high-risk, some of which may require caesarean section. Of late, the incidence of caesarean section is steadily rising. In the last few decades, the caesarean rates have increased dramatically in the developed world. Amongst developing counties like Brazil and China also, the caesarean section rates have sky-rocketed. In India, data collected from 30 medical colleges/ teaching hospital revealed that caesarean section rates increased from 21.8% in 1988-89 to 25.4% in 1993-94. A population based cross-sectional study conducted in India, a caesarean section of 32.6% has been documented from Madras City in South India.  Clearly these rates are unacceptably high all over the globe. We conducted the present study to find out the prevalence of caesarean section in an urban community of East Delhi.
The present study was a cross-sectional population based enquiry and lasted from September 2003 to May 2004. The study was conducted in an urban community of East district in East Delhi, namely Vivek Vihar. Vivek Vihar is a geographically well defined community and its residents belong to upper middle and rich socio-economic strata. The colony has 1120 houses and a universal coverage of all the houses was done. All the families residing in all the houses in all the four blocks, namely A, B, C and D, were covered by house to house survey. Only those houses could not be covered which were found locked on three consecutive visits. The families of maids and servants were excluded. Data was collected from mothers having under five children born on or after 1 st January 1999. A list of all houses and families residing in them was obtained from Residents' Directory from the Resident Welfare Association. Data was collected by a team of 29 MBBS students of 3 rd and 4 th semesters posted in the Department of Community Medicine. Each student was allotted 38 houses (1120 divided by 29). Data was collected on a semi-structured, semi open-ended proforma. Subsequently, all the data was entered into a master chart and then entered in MS-Excel, from where it was transferred to SPSS software. Subsequently appropriate test of significance were applied and multiple regression was used to delineate the predictors for caesarean section.
A total of 419 deliveries were reported in Vivek Vihar during the study period. Eighty seven percent mothers were housewives while the rest were employed, 55.6% of children belonged to first birth order, 37% were of birth order 2 and only 7.4% were of birth order 3. Majority (88.8%) of the mothers had no health problem during their pregnancies while 4% had hypertension, 1.4% had diabetes and one mother suffered from tuberculosis. Except three deliveries (0.7%), which were domiciliary deliveries, rest were institutional deliveries. Ninety two percent deliveries were conducted in private hospitals/nursing homes and only 7.6% in government hospitals. Eighty eight percent of the mothers had delivered at term (37-40 weeks) while 9.1% had pre-term delivery (<37 weeks) and 2.6% had post term delivery (>40 weeks). One hundred and forty four (34.4%) deliveries in the present study were caesarean and rest were vaginal deliveries. Of the caesarean deliveries, 54.9% were emergency caesarean and 45.1% were elective caesarean deliveries. The main indications of caesarean section were fetal distress (22.9%) followed by post caesarean pregnancies (21.5%) and the failure of progression in labour (11.8%). The main indications for elective caesarean section were post caesarean pregnancy and cephalo-pelvic disproportion while fetal distress and failure of progression of labour were the chief indications for emergency caesareans. This difference amongst emergency and elective caesarean indications was statistically significant ( P <0.05).
To find out the association of various factors with the type of delivery (caesarean/vaginal) we made 2x2 tables and applied Chi-square test [Table - 1]. It was found that caesarean section were significantly higher in those deliveries which were either pre-term/ post-term or amongst mothers who had some health problems during pregnancy compared to term delivers and those not having any health problems during pregnancy ( P <0.001). Subsequently, we performed multivariate analysis for finding out the predictors of caesarean section. The adjusted ORs and its 95% CI are given in [Table - 2]. Again it was found that health problems during pregnancy and pre-term/ post-term deliveries were the predictors for caesarean section (OR 2.8 and 3.8, P <0.001 respectively) though private hospital/ nursing home deliveries also had OR > 1 but the result was not statistically significant ( P <0.05).
The results of our study demonstrate that the prevalence of caesarean section (34.4%) was unacceptably high. Similar high caesarean rates of 32.6% have been reported from the only available community based study from Chennai, also such high rates cannot be explained on the basis of obstetric/ fetal factors alone. Though some increase in the caesarean section rates over the recent years can be explained by obstetricians "playing safe" (i.e., conducting caesarean for even minor complications and avoiding litigation problems) or performing caesarean for astrological reasons (Parents want the child to be born under favorable heavenly bodies constellations) and obstetricians avoiding 'night calls' (where by obstetricians tend to avoid odd hours for conducting deliveries), still that can not explain high caesarean section rates.
Majority of caesarean deliveries (91.7%) in our study were conducted in private sector. Obviously some commercial interests may be at work as there is a large difference of expenditure in a caesarean and vaginal deliveries and our study also shows that patients in private hospital were 14 times more likely to incur an expenditure of more than 15000/= rupees as compared to government hospitals and the difference amongst them was statistically significant ( P <0.05).
The large unregulated private sector seems to be making a 'killing' by resorting to many unjustified caesarean section deliveries. In fact the first author has reported in another study, the prevalence of caesarean of just 2.5% in a resettlement colony namely Nand Nagri (earlier this was a cluster of hutments and later on the population residing in them were given 25 sq yard houses) just one kilometer from UCMS and GTB Hospital. In Nand Nagri, only 62.2% deliveries were domiciliary and only 38.2% were hospital based and majority of them were in govt. hospital since the residents there, majority of whom belong to lower socioeconomic strata could not afford expenditure in private hospital. In the present study only 8.4% deliveries were domiciliary deliveries. Similar results depicting higher rates of caesarian section amongst private sector has also been shown in NFHS-2 data from Kerala where after controlling for demographic variables, the odds for caesarean section was about 1.7 times more likely to occur in a private health institution. Caesarean section is a lucrative surgical procedure and therefore commercial interest may well have been the motive force behind the exceptionally high rate and many of these procedures may not have been to the benefit to the mother or fetus. To further ascertain these aspects we enquired mothers about their perceptions regarding some aspects of caesarean section. Half of the respondents, i.e., 49.6% replied in affirmative that doctors/ hospitals were deliberately opting for caesarean deliveries instead of normal vaginal deliveries twenty seven percent respondents felt that the expenditure charged for caesarean section were not reasonable. This despite the fact that the study subjects belonged to high socio economic strata. Forty five percent respondents even felt that they could not afford expenditure for caesarean section. Thirteen percent mothers actually felt that caesarean section on them was not justified and that they should have been delivered by normal vaginal method.
In our study, the main indications for caesarean were foetal distress, post caesarean pregnancies and failure of progression of labor. Results similar to these have been reported from a case control study in Delhi to find out the various modes of deliveries in relation to presence of different risk factors.
It is well documented that caesarean section carries a much higher maternal mortality and morbidity as compared to a vaginal delivery. Even though caesarean section is being performed for indications like foetal distress, perinatal mortality continues to be very high among in caesarean section deliveries.
While more such community based studies should be carried out in the others parts of the country, efforts should be made to promote vaginal deliveries and bring down the rate of caesarean section as it shall be beneficial to both mother and foetus and also minimize yet another misuse of technology driven health care system.
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