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ComplicationSafety.html
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---
layout: default
title: Complications, Safety and Caesarian section rates
---
<h1>Complications, Safety and Caesarian section rates</h1>
<p class="bold">
“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)
</p>
<p>
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?
</p>
<matrika:video clip="/Clips/Clip2_EarlierHealthy.video" width="384" height="288" />
<p>
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.
</p>
<h2>Safe Motherhood – Bureaucracies and Babies</h2>
<p>
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.
</p>
<p>
According to a prominent obstetrician representing the Federation of
Obstetricians and Gynecologists at a Safe Motherhood meeting
</p>
<p class="bold">
“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. ”
</p>
<img class="well center" src="/assets/images/motherhood2.jpg" width="370" height="398" />
<p>
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
<strong>right to Safe Motherhood</strong>
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.
</p>
<img class="well center" src="/assets/images/motherhood3.jpg" width="370" height="275" />
<h2>The Caesarean Epidemic</h2>
<p class="italic">
(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)
</p>
<p>
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.
</p>
<p class="bold">
(US Mishra and Mala Ramanathan “Delivery-related
complications and determinants of caesarean section rates in
India ” Health Policy and Planning; 17 (1) 90-98)
</p>
<p>
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."
</p>
<p>
" 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. "
</p>
<a href="http://www.nchc.org/Berwick.html" target="_blank">(National Coalition on Health Care Report .D. B. Berwick)</a>
<p>
In Sweden the caesarean section rate declined from 12% in 1983, the
highest it had ever reached there, to 10.8% in 1990.
<b>At the same time perinatal mortality rates were reduced by half.</b>
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. (<b>Sheila Kitzinger, The Politics of Birth</b>)
</p>
<img class="well center" src="/assets/images/caesarean.jpg" width="347" height="227" />
<img class="well center" src="/assets/images/Caesarean-Birth.jpg" width="349" height="241" />
<p>
"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." (
<b>Francome, C.,Savage, W., Churchill, H. and Lewison, H. 1993. Caesarean Birth in Britain. London: Middlesex University Press.</b>)
</p>
<p>
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." (
<b>World Health Organization, 1992. International
Differences in the Use of Obstetrical Interventions</b>
)
</p>
<p>
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>B.L. Flamm and E.J.Quilligan, Editors. 1995. Cesarean
Section: Guidelines for Appropriate Utilization. New York:
Springer-Verlag.</b>
)
</p>
<p>
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:
<a href="http://www.ihi.org/resources/btsguides/" target="_blank">Institute for Healthcare Improvement</a>
</p>