The rate of cesarean sections performed without medical necessity is a matter of clinical and ethical concern
- During my research, I found a lack of comprehensive counseling where doctors seemed to fulfill formalities rather than providing adequate guidance to patients
Maria Mansoor Memon
Childbirth is a transformative event in a women’s life and the method of delivery can significantly impact both the maternal and neonatal health outcomes. The cesarean deliveries are the high risk of maternal and neonatal heath however the vaginal delivery is the natural mode of childbirth. The C section is often necessary and in certain situations it is lifesaving action. The emergence of the cesarean section (C-section) as a life-saving procedure traces its roots back to ancient history, possibly originating from practices in Rome. However, in contemporary times, C-sections have transitioned from being a necessity for emergencies to becoming a concerning trend, especially when performed without medical indications. This growing trend, notably prominent in countries like Pakistan, has prompted a six-month-long research project aimed at understanding the societal discourse surrounding C-sections. The study sought to delve into the socioeconomic factors and cultural beliefs that contribute to the increasing rate of C-sections. It also aimed to explore the roles of gynecologists, midwives, and their impact on decision-making during delivery. One of my research arguments are about the Gynaeocologists role in the public healthcare settings and delivery decision making that I’m going to present in the article,
Research ethics
In accordance with anthropological research ethics, the research refrains from disclosing the real names of doctors, patients, or families and also the hospital name where I had done my research to ensure the privacy of individuals. Instead of using real names, fake names have been employed, and any pictures included of patients or doctors have been used only with their explicit consent.
Role of gynecologists in the context of decision-making regarding c section in public healthcare settings
In some cases, gynecologists in public hospital appeared to prioritize the actual delivery process over counseling. When patients expressed a preference for natural vaginal delivery (NVD), the doctors often opted for C-sections without thoroughly guiding or counseling the patients on the reasons for this decision. Conversely, if a patient requested a C-section without medical necessity, the doctors did not consistently provide comprehensive guidance on the advantages of NVD. Ultimately, it seemed that the decision to perform C-sections was based on the patient’s choice and, in some instances, without adequate informed consent.
Assessment
According to doctors, the increasing rates of C-sections can be attributed to two main factors. Firstly, it may result from the maternal wish for the procedure, where some women prefer to undergo a C-section rather than experiencing the pain of natural childbirth. Secondly, a lack of good nutrition among women could also contribute to the rising occurrence of C-sections. Additionally, in some cases, doctors are believed to play a role in the increasing rates, both due to patients’ requests and potential issues with proper counseling, as some doctors may not adequately counsel their patients on the risks and benefits of different delivery methods. Fareed OT technician at LUMHS said that,
“One of the causes of the increasing C-section rates is a weakened immune system, often a result of females neglecting their dietary care. Additionally, technological factors play a role; if the baby is in a breech position, some doctors may opt for a C-section, and private doctors might contribute to this trend by suggesting C-sections even in cases with manageable risks. The Staff nurse Maheen stated that,
“C-sections have become a trend, almost a fashion statement, where people opt for it to avoid pain. Some women initially visit private hospitals, where doctors might suggest C-sections citing limited space in their pelvic bones. When they later seek care in government institutes, they find themselves compelled to undergo C-sections due to the previous surgical deliveries.” The HOD of the hospital stated that,
“The increase in C-sections can be attributed to various factors. Firstly, both doctors and patients share responsibility for this trend. Secondly, a significant contributing factor is the inadequacy of the nutritional system. Nowadays, new-generation doctors often don’t allocate sufficient time for patients, including during labor and childbirth. Furthermore, the number of doctors, including untrained individuals, practicing in both rural and urban areas has surged. Additionally, the prospect of higher earnings and time efficiency has led to the rise in C-sections.”
Informed consent
Informed consent during doctor interviews can vary depending on the circumstances. In some cases, when there is a risk associated with the delivery, doctors obtain consent in a formal manner through a written consent document, often provided in Sindhi, containing all the necessary information. This process applies, for instance, to elective C-section cases. However, in emergency situations, patients might not receive detailed guidelines but are presented with a document for signature. If complications arise during delivery, the medical team may not always provide a thorough explanation. The patient’s mother stated that,
“My daughter had undergone a C-section for the birth of twins. Three days later, the stitches appeared to have deteriorated, leading to a critical situation that required an emergency visit. Subsequently, doctors performed a second operation and reapplied the stitches. Despite attempts to ascertain the reasons behind these actions, the medical team did not provide a satisfactory response. The patient’s mother expressed concerns about the doctors’ handling of the situation and the fact that her daughter’s narrowly escaped a life-threatening outcome.”
The OPD registrar told us that, “We firstly guide patients, and if it’s a case of NVD, we don’t perform a C-section. If the patient’s family don’t agrees, we have them sign the consent papers, and then explain everything in Sindhi.
Monitoring
The lack of adequate one-on-one patient monitoring is a concerning issue, and many patients feel neglected as doctors often seem reluctant to engage with them individually. There have been distressing incidents where patients, especially from underprivileged backgrounds like the Baloch community, were dismissed or scolded when seeking help. For instance, a woman tearfully shared that her son’s wife abortion procedure led to serious complications, yet doctors initially showed no response until her son’s wife condition worsened, prompting an emergency intervention. “This situation reflects a distressing trend where doctors exhibit negligence or engage in micro politics within their ranks, leading to a lack of accountability and sincere care for patients. Some doctors prioritize their peers over attending to patient needs, creating an environment where patient welfare takes a backseat. While some medical staff attribute the deficiency in one-on-one monitoring to a shortage of personnel, it remains unacceptable that even with fewer doctors, they fail to fulfill their duties adequately, potentially endangering patients’ well-being through inadequate attention and care.
The Emergency situation
In emergency situations, patients and their families often endure significant distress before receiving admission. It’s observed that hospitals tend to delay admitting patients until their condition deteriorates significantly. Families have reported that, “Doctors arrive during emergencies and exercise their discretion in responding to critical conditions. They rush in, often making a last-minute effort to obtain consent through hurriedly obtained signatures on forms, then swiftly proceed with operations.”
From my observations, it seems that doctors remain excessively relaxed, regardless of the severity of a patient’s condition. They prioritize obtaining consent forms swiftly, sometimes without adequately informing or discussing the details with the patient or their family. There’s concern that patients might not fully comprehend the exact contents or implications of what they’re signing on these consent forms amidst the urgency of the situation.
Patients’ preference
When discussing a patient’s preference for the mode of delivery, it appears that government doctors typically do not perform a C-section without medical indications. However, in cases where a patient with a preference for a normal vaginal delivery (NVD) ends up undergoing a C-section, there seems to be a lack of clarity regarding the reasons behind this decision. During an interview with a doctor, it was revealed that, “We refrain from performing a C-section without complications. In situations where a patient threatens legal action, they opt for a C-section similar to obtaining consent. “In interviews with a patients who had undergone an emergency C-section, it was mentioned that, “During in our emergency situation, the decision for the C-section was made by the family and the doctor, and we were not fully aware of the reasons behind it.” When the patient inquired about the reasons for the C-section, they were told that it was due to a contracted or small pelvis space. “Observations indicate that even in emergency C-section cases, patients often remain unaware of why a C-section was performed, leading to confusion. Furthermore, patients might not feel empowered during the delivery process and tend to rely entirely on their families, who in turn follow the instructions given by the doctors. Consequently, families may also lack awareness about potential complications.
The role of gynecologists is pivotal in ensuring effective communication between patients and healthcare providers. However, there appears to be a noticeable communication gap, particularly in public hospitals.
Ethical consideration
Moreover, regarding ethical consent, there are significant disparities in public settings, patients often lack awareness of the consent forms they are signing. Conversely, it’s crucial for doctors to ensure that patients fully comprehend and consent to procedures according to ethical guidelines, especially considering that not all patients are well-educated or proficient in languages like Sindhi, which might hinder their understanding of ethical consent documents. During observations, many patients opted for C-sections due to various reasons, including medical concerns, doctor recommendations, and societal influence, where some women followed a blind imitation trend of opting for C-sections assuming it to be the preferred choice. (Doctors recommendation is one of the major reason of C-section.
Conclusion
During my research, I observed a micro-political dynamic among doctors regarding patient care in public institutes. There was a lack of comprehensive counseling where doctors seemed to fulfill formalities rather than providing adequate guidance to patients. In interviews, senior doctors mentioned that, “counseling did occur, but sometimes inadequately due to a higher patient load and a lower doctor-to-patient ratio. Additionally, illiterate patients often visited, creating challenges in effective communication, leading to irritation among junior doctors. The rate of cesarean sections performed without medical necessity is a matter of clinical and ethical concern, varying significantly globally, ranging from 2.6% in Flanders to 26.8% in Western Australia.
Read: C-Section (Cesarean Section): Procedure, Risks & Recovery
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Maria Mansoor Memon is graduate in Anthropology, specializing in Medical Anthropology. During her student life, she authored numerous research articles in both Sindhi and English. Following her graduation, Maria participated in national and international conferences as a researcher, showcasing her expertise. Currently, Maria serves in the health department of Sindh Integrated emergency and health service 1122, specifically as part of the station management team.
