With late marriages taking place at the peak of PCOD and metabolic syndrome, misinformed Kashmir mothers have grown too intolerant to labour pains as a result of which Jammu Kashmir is emerging as the capital of caesarean birth, reports Syed Shadab Ali Gillani and Babra Wani
In 2022, Mehwish embarked on the journey of marriage and motherhood, expecting a life filled with joy and promise. At 24, she was eager to start her new life, and the news of her pregnancy only added to her happiness. Her elation was, however, short-lived.
As her due date approached, Mehwish’s older cousins shared their own harrowing experiences of childbirth, filling her with trepidation. “They told me so many scary things about delivering the baby that the clouds of fear overshadowed the happiness to conceive,” Mehwish recalled. “I became afraid at the thought of delivering normally.”
Despite her gynaecologist’s reassurances that her body was capable of normal delivery, Mehwish’s fear only intensified. “Whenever I thought of a normal delivery, I started having goosebumps, and I decided not to move ahead with it,” she said. Her parents and doctor advised against surgical intervention, but Mehwish was resolute.
Now, almost two years after her delivery, Mehwish regrets her decision. “My body feels like that of a 40-year-old,” she lamented. “I am only 26, but I feel so old and aged. I have developed a constant backache since that day. Surgery took away the youth from my body, and I get so tired now.”
Mehwish’s story is not an isolated one. Many women, driven by fear and misinformation, opt for surgical interventions, unaware of the potential long-term consequences. As Mehwish’s narrative illustrates, the fear of labour and delivery can have a profound impact on a woman’s life, leading to unforeseen and far-reaching effects on her physical and emotional well-being.
A New Trend
The rise of caesarean births is a huge trend in India. The last National Family Health Survey (NFHS-5) reveals a significant spike, soared to 21.5 per cent, surpassing the World Health Organisation’s (WHO) recommended range of 10-15 per cent.
The WHO’s research underscores the risks associated with unnecessary C-sections. “Worldwide, Caesarean section rates have risen from around 7 per cent in 1990 to 21 per cent in 2021,” the UN body notes, projecting a continued increase throughout the decade, with a staggering 29 per cent of all births expected to be delivered via C-section by 2030.
The Caesarean Capital
NFHS-5 data reveals a disproportionate distribution of C-sections across India. Jammu and Kashmir, for instance, has witnessed a remarkable 25 per cent increase in C-sections, with 41.7 per 100 births, trailing only Telangana (60.7 per cent), Tamil Nadu (44.9 per cent), and Andhra Pradesh (42.4 per cent). This surge raises critical questions about the factors driving this trend and the potential consequences for maternal and infant health.
In the bustling corridors of Lal Ded Hospital, a striking trend has emerged. The latest data reveals that in 2021-2022, a staggering 63.5 per cent of all deliveries were Lower Segment Caesarean Sections (LSCS), with 13,462 cases recorded, compared to 7,723 Normal Deliveries (ND). An earlier study, spanning November 2020 to February 2021, found that the Caesarean section rate at Lal Ded was a whopping 64.2 per cent.
Advocate Badrul Duja Khanyari’s Right to Information (RTI) inquiry sheds further light on the situation. The data reveals a consistent pattern across various hospitals in the region. At Sher I Kashmir Institute of Medical Sciences, Soura, for instance, the total number of LSCS procedures (20,217) far outstripped Normal Deliveries (9,127) between 2011 and 2020.
In the Government Lalla Ded Hospital, Srinagar, the only major hospital for gynaecology and obstetrics, Caesarean deliveries (84,820) exceeded Normal Deliveries (52,029) from 2015 to December 2020. This trend persists across other hospitals, including SKIMS Medical College and Hospital Bemina, Srinagar, and government hospitals in Shopian, Nagam, Tangdar Karnah, and Kulgam.
The sheer volume of data paints a disturbing picture, warranting a closer examination of the underlying causes and potential consequences of this alarming rise in Caesarean sections in Kashmir. As the numbers continue to rise, it is essential to investigate the factors driving this trend and address the implications for maternal and infant health in the region.
A Cultural Shift
According to Dr Qazi Haroon, former State Project Manager of the National Rural Health Mission (NRHM), a significant factor contributing to this shift is a perceived decline in pain tolerance among women.
“There is a notion that C-section is very easy to do, and it is painless,” Dr Haroon explains. “Now it is very easy, everything is automatic. It is like if you go to a hospital, you ask a gynaecologist to go for an LSCS, she opens you up and delivers the baby in half an hour, so no pain, nothing.”
Dr Haroon’s observations highlight a pervasive cultural mindset, one that views Caesarean sections as a convenient, pain-free alternative to natural birth. However, this perception belies the potential risks and complications associated with surgical intervention. In response, healthcare professionals have launched initiatives aimed at raising awareness about the merits of natural delivery.
“We have been trying to create awareness because the numbers are very staggering,” Dr Haroon notes. “We wanted to create awareness that C-sections are abnormal. We started family counselling about eight months ago, in which we convince the mother of the merits of normal delivery.”
Natural Deliveries
In a bid to encourage expectant mothers to opt for natural deliveries, the Jammu and Kashmir administration has launched an early sensitisation and behavioural change communication programme. The initiative aims to educate pregnant women and their families about the benefits of normal delivery, amidst a growing trend of C-sections.
The move comes as part of the government’s efforts to promote natural deliveries under the Ayushman Bharat package, which does not cover C-sections to prevent their indiscriminate use. “We wanted to encourage normal deliveries, particularly in remote areas where they are still prevalent,” the official said. “However, overall, C-section rates remain high, and we need to create awareness about the risks associated with this procedure.”
Jammu and Kashmir has made significant strides in institutional deliveries, with a remarkable 98.2 per cent of deliveries taking place in hospitals, making it the second-highest in the country over the past decade. This achievement is attributed to the Janani Shishu Suraksha Karyakaram (JSSK) scheme, launched in 2011, which provides free delivery services to parents. However, the scheme that envisages extending all possible help to the expecting mother is not well advertised.
The government has also enlisted the support of over 12,000 Accredited Social Health Activists (ASHA) workers, who counsel women and families, preparing them for normal deliveries and providing guidance on breastfeeding, family planning, immunisation, and contraception.
In 2018, the Ministry of Health and Family Welfare laid down guidelines on midwifery services, focusing on promoting quality, continuity of care, and women-centric care to encourage natural births.
However, the preference for C-sections persists, as exemplified by Khalida, a young woman who opted for a C-section to avoid the pain and struggles associated with natural delivery.
Personal Dilemmas
Khalida’s journey to motherhood was marked by a deliberate choice – one that has left her grappling with the consequences. In 2023, upon learning of her pregnancy, she engaged in thoughtful discussions with her husband about opting for a Caesarean section. Despite her husband’s understanding of her concerns, he ultimately deferred to her decision, acknowledging that he has the right to decide on something she is fundamental to. “It is she who bears the pain of having a child, literally and figuratively,” he explained. “She has undergone immense physical and hormonal changes, so I felt it was not my place to dictate her choice. I respected her decision.”
The couple welcomed their first child earlier this year, and while they revel in parenthood, Khalida’s recovery has been arduous. “The surgery took a toll on me,” she revealed. “I have developed a spinal disc issue, and my body feels weaker. I have gained a newfound respect for my mother, now that I am a mother myself. We endure so much pain, and having a Caesarean is daunting. It took me over three months to regain some semblance of normalcy, and I am still recovering.”
Khalida’s gynaecologist had cautioned her against the Caesarean, but her fears were fuelled by friends’ accounts of the pain and bodily changes associated with natural delivery. “In hindsight, it may prove reckless, but I did not have the strength or courage for a natural delivery,” Khalida admitted. “The labour pain can persist for days, and I lacked the patience. That is why I thoroughly discussed it with my husband.”
Cause for Concern?
Nigaar, a woman in her mid-thirties, is another example. She underwent a C-section for her first pregnancy and, subsequently, for her second delivery as well. However, her second experience was far from straightforward. “My second baby developed some complications, and doctors performed another emergency C-section,” she recounts. “But she also suggested that I should be more careful if I conceive again, as a normal delivery in the third pregnancy will be next to impossible.”
Saba, another resident of Kashmir, shares a similar story. She conceived twins twice, both times delivering via C-section. Her doctor advised against a third pregnancy, citing potentially fatal consequences. “My sister had a C-section because her baby had ingested something toxic in the womb, and an emergency C-section was performed to save the baby,” Saba explains. “I think it is very difficult, but at the same time, a saviour at times. For me and my sister, both of us, it is a saviour because we had very complicated pregnancies, and our only way out was a C-section.”
The NFHS-5 reveals a striking disparity in C-section rates between public and private hospitals in Jammu and Kashmir. A staggering 82 per cent of deliveries in private hospitals are via C-section, compared to 43 per cent in public hospitals.
Besides, the survey indicates that C-sections are no longer exclusive to urban areas. While metropolitan regions report a high 54.7 per cent C-section rate, rural areas, where such procedures were previously uncommon, now record a significant 37.8 per cent rate.
A closer examination of district-level data reveals that the Kashmir division is home to most districts with high rates of C-section births. Pulwama district in south Kashmir leads the list, with an alarming 61 per cent of C-sections, followed closely by Srinagar.
A Complex Issue
Dr Farhat Jabeen, a renowned gynaecologist and professor, and former Head of the Department of Obstetrics and Gynaecology at Government Medical College, Srinagar, offers a nuanced perspective on the increasing rate of C-section deliveries in Kashmir. “C-section rates have increased in the entire world, but they are more prevalent here,” she notes.
Dr Jabeen attributes the rise to a multitude of factors, explaining that the nature of pregnancies has changed over time. “When we used to see pregnancy as normal, we would get 100 patients, out of those 100 patients, we had 60 patients who were up for normal deliveries. Now, the ratio has reversed. We have pregnancies with complications and incidences more than patients who have normal pregnancies.”
Some key factors are usually overlooked. “The age of marriage has gone up from 20 to 30, leading to infertility issues. Additionally, patients are experiencing issues like Poly Cystic Ovarian Disorder (PCOD) and metabolic syndrome disorders.” Dr Jabeen’s insights highlight the complexity of the issue, suggesting that the rise in C-sections is not merely a matter of choice, but rather a response to the changing health landscape of pregnant women in Kashmir.
By examining the underlying factors driving this trend, Dr Jabeen’s expertise provides a thoughtful counterpoint to the alarming statistics, inviting a more informed discussion on the implications of this shift for women’s health in the region.
“So, it makes overall pregnancy at high risk,” she begins. “The other thing is when infertility increases, all these patients who are not conceiving, go for Assisted Reproductive Treatment (ART), like in In-Vitro Fertilisation (IVF) pregnancies, making another high-risk group.”
Elaborating on the complexities of modern pregnancies, she highlighted the desire for a “precious pregnancy” free from complications. “They don’t want to take any chance,” she notes. Besides, she points out that elderly age groups often present with pre-existing medical disorders, while younger patients may opt for pain-free labour, leading to an increased demand for epidural anaesthesia – a luxury not readily available in the government sector and accompanied by its own set of complications.
Dr Jabeen’s expertise reveals a stark contrast between the past and present. “Initially when I started my career, I would hardly see any patient with diabetes,” she recalls. “Now, I see hardly any patient who doesn’t have diabetes. This is the scenario. This is what has changed abruptly.” Her words paint a vivid picture of the evolving landscape of women’s health in Kashmir, underscoring the need for a thoughtful and multifaceted approach to addressing the rising Caesarean section rate.
Hidden Risks
According to Dr Jabeen, the repercussions of this surgical procedure on a woman’s body cannot be overstated.
“It is an operative way, an abnormal route for delivery,” Dr Jabeen explained. “You must go into the abdomen, making the patient more prone to infection. The patient faces increased risks of haemorrhage and iatrogenic prematurity. Additionally, there’s a higher chance of baby respiratory distress during delivery. Even in top-notch institutions, post-operative complications like sepsis and infection remain a concern.”
Dr Jabeen’s concerns are particularly pertinent in the Indian context, where the private sector has been accused of prioritising profits over patient care. “In our setup, it is more severe, especially in the private sector. They celebrate, forgetting that the patient is inside. Chances of infection are very high.”
The interventions do have long-term consequences on a woman’s reproductive health, the practitioner admitted. “It leaves a scarred uterus, so the second time if they conceive, even if they want a normal delivery, the chances of the scar giving way are high. There is a 0.3 per cent risk of having a scar dehiscence that needs close monitoring.”
The risks extend to the child as well, Dr Jabeen noted. “If we do elective caesareans, there are more chances of respiratory distress. Breathing issues are more common with caesarean babies than with normal deliveries, even if done at the proper time. There are more chances of having breathing issues than in normal delivery.”
Dr Jabeen emphasised the importance of exploring alternative options before opting for a caesarean section. “Without indication, one should not go for a caesarean section. One should at least give a trial for normal delivery. But normal delivery is not only the domain of the obstetrician. The patient must give consent for it. The patient must bear the labour pains. The patient must tolerate labour pains, and if everything goes smoothly, she can deliver. If everything does not, even after labour pains, she may end up in a caesarean section. That is an indicated caesarean section.”
The Surgical Solution
Dr Ian Askew, Director of the World Health Organisation’s (WHO) Department of Sexual and Reproductive Health and Research and the Human Reproduction Programme (HRP) throws his weight behind the critique against the surging caesarean cut numbers. “Not all Caesarean sections carried out at the moment are needed for medical reasons.”
The WHO’s stance is supported by a plethora of evidence indicating that C-sections are being performed far more frequently than necessary worldwide. This trend raises important questions about the motivations behind this shift and the potential consequences for maternal and infant health.
In situations where normal delivery is compromised, C-sections can be a lifesaving intervention. Surgical intervention is the only option left in cases of Placenta previa, vaginal obstruction, failed labour induction, advanced cervical cancer, bladder rupture, foetal distress, foetal malposition or malpresentation, comorbidities, and hypertension are all legitimate indications for surgical intervention.
