Title: Increasing caesarean section delivery: A threat to urban women’s health? Authors: Sancheeta Ghosh* and K.S James† Introduction: A consistent increase has been observed in the rate of caesarean section deliveries in most of the developed countries and in many developing countries including India over the last few decades derivate a matter of concern among the social scientists. In recent years, especially in parts of world, it is often argued that with thriving private practice, obstetricians increasingly prefer for medicalised birth than normal birth. In addition, there is also some evidence from Western countries on increasing preference from women who want to deliver their child through the c-section. The rates of caesarean section in many countries have increased beyond the recommended level of 5-15 % by WHO, almost doubling in the last decade. In high income countries like Australia, US, Germany, Italy and France, the rates have gone phenomenally (Sufang et.al, 2007). The present data shows that in United States, 1.2 million or 29.1 percent of life births were by c-section delivery in the year 2004 (NIHS, 2006). Of the 12 Latin American countries reviewed recently Brazil had the highest rate of c-section (Behague et al. 2002). Similar trends have also been documented in low income countries such as Brazil, China and India, especially for births in private hospitals (Potter et al. 2001; Cai et al. 1998; Mishra and Ramanathan, 2002). In a developing * Research Associate at International Centre for Research on Women, New Delhi. † Professor and Head, Population Research Centre. Institute for Social and Economic Change (ISEC), Bangalore Here the term caesarean delivery and c-section delivery are used interchangeably. 1 country like India there is an increasing trend of c-section delivery with increase in the institutional deliveries and growing access to gynaecological and obstetric care. A study by Indian Council of Medical Research (ICMR) in 33 tertiary care institutions noted that the average caesarean section rate increased from 21.8 percent in 1993-’94 to 25.4 percent in 1998-’99 (Kambo et al. 2002). According to the National Family Health Survey, 1992-’93, the two states Kerala and Goa have shown the highest percentage of c- section deliveries (Mishra and Ramanathan, 2002). A rising trend in c-section rates, from 11.9 percent in 1987 to 21.4 percent in 1996 have been reported from Kerala (Thankappan, 1999). Another study in Jaipur showed that c-section rates in a leading private hospital rose from 5 percent in 1972 to 10 percent in late 1970s and to 19.7 percent between 1980-’85 (Kabra et al. 1994). Studies also suggest that one of the important factors behind performance of c-section could be high education background of women, more presence of private hospitals or sometime interplay between doctors’ motivation and financial incentives of the hospitals behind such trend. The current paper, thus, will be an attempt to discuss the ongoing debate on caesarean section scenario in India and with special emphasis to medicatiozation of maternal health in urban areas. While doing so, it also tries to throw light on current trend on c-section births in India and states, particularly focusing on urban areas. An attempt has also been made to explore the voices of others who had caesarean births to understand the mechanism of performance of c-section even without any medical reason. Why urban women? Until recently, urban health was not the main focus of public health policies in most developing countries since the majority of the population lived in rural areas (Gupta et.al. 2 2009). It was often assumed that the heavy concentration of health facilities and personnel in urban areas, particularly in the private sector, would automatically take care of the increasing urban population and its health needs. However, the rapid growth of cities in developing countries, together with the growth of the urban poor and inequities created within cities, made this position untenable (Rossi-Espagnet, 1984). The urban population also has access to a wider range of health care options, particularly in large cities, due to the better-developed health infrastructure. However, accessibility to these services and the quality of the services vary greatly between cities and within cities (Poel, O'Donnell, and Doorslaer, 2007; Lalou and LeGrand, 1997). Moreover, what is more critical to discuss here that the over use of health facilities, most of the times, creates concern for health of the urban people and more specifically urban women. Medicalisation of maternal health and Caesarean delivery: The rising trend in c-section rate in both developed as well as developing countries, increasing preference from medical professionals rightly points towards growing medicalisation of health in the society. This growing reliance on medicine also appeared to be occurring in other aspects of life such as childbirth, menopause, and ageing (Zola, 1972, Freidson, 1970). A number of studies in this context elucidate that over the past few years, dependence on medical intervention during childbirth have gone up to combat with maternal and child death. Hence, a growing number of deliveries are taking place through surgical intervention resulted in a high rate of c-section in both developed as well as developing countries. It is well known fact that the maternal and neonatal deaths have significantly come down in the last century in large part as a result of the increased application of technology during labour and childbirth (Sen, 1994). But what is more 3 concerning is the overuse or misuse of the medical technology for profit motive or risk avoiding in health care facilities. Objectives of the paper: In light of the above situation the current paper tries to explain the current scenario of caesarean births in India and states and the urban context of increasing caesarean delivery within the medicalisation framework. Data and Method: For the purpose of the current paper, a mixed method has been used. The first part of the analysis is based on analysis of secondary data from National Family Health Survey (All 3 rounds, from 1992-2006) to explore the current trend and level in c-section births in India and states. The next step involved a qualitative approach to understand the decision making for the performance for caesarean births. Discussion: Emerging pattern in caesarean births in India and states: For the present analysis data is taken from the National Family Health Survey (NFHS) of three consecutive periods (1992-1993, 1998-1999 and 2005-2006). In NFHS, mothers were asked whether they had caesarean delivery during three years preceding the survey. The data analyzed for three surveys to see the trends in c-section delivery in India and states. Reliable data on the incidence of c-section is available in India only from the first round of NFHS conducted during 1992-93. Hence, the trend of c-section deliveries analyzed from 1992-93 to 2005-06 which shows that there has been an upward trend in c- 4 section rates in India. Figure 1 presents the trends in c-section deliveries in India for the periods 1992-93 to 2005-06. At all India level, the rate has increased from 2.9 percent of the childbirth in 1992-93 to 7.1 in 1998-99 and further rise to 10.2 percent in 2005-06. The difference in c-section delivery from NFHS-1 to NFHS-3 is relatively high in states like Andhra Pradesh, Goa, Kerala, Tamil Nadu, West Bengal and Punjab. A rapid increase in c-section rates have occurred in these states from 1992 to 2006. The rate is highest (27 percent) in the state of Andhra Pradesh in 2005-06 (although the rate was as low as 4.4 percent during 1992-93 in the state). Figure 1 Percentage of C-section delivery from 1992-93, 1998- Percentage1998- of C-section births 12 10 99 and 2005-06, India 10.6 8 7.1 6 4 2.9 2 0 1992-93 1998-99 2005-06 Figure:1 Trend in caesarean section delivery over the decade: However, this scenario itself can not be considered as a sharp increase, nor the figure exceeds the tolerable limit specified by the WHO. In fact, the rate of increase has marginally declined if we compare 1992-93 to 1998-99 with 1998-99 to 2005-06. What has been alarming in the case of India is the wide heterogeneity in the incidence of c- section across states and regions. It is evident from the analysis in Table 1, that in 2005- 5 06, 7 out of 19 states reporting over 15 percent or more caesarean child birth. Over the last 15 years the increase in c-section delivery has been substantial in many states in the country. Interestingly, all the southern states in India recorded c-section delivery as high as that of recorded in countries with highest level of c-section in the world. The rates recorded in Kerala, Andhra Pradesh and Goa is alarming. The data indicate that, states with marked demographic transition also records high incidence of c-section rate, although, the real cause of such increase would be different. Table 1: Percentage of women who had undergone caesarean section delivery by states*, from NFHS-1, NFHS-2 and NFHS-3. States Percentage of women who have caesarean delivery NFHS-1 NFHS-2 NFHS-3 Diff from (1992-’93) (1998-’99) (2005-’06) NFHS-1 Uttar Pradesh 0.6 2.7 5.9 5.3 Haryana 2.3 4.2 5.0 2.7 Himachal Pradesh 1.6 6.8 13.1 11.5 J&K 5.7 10.6 14.1 8.4 Punjab 4.2 8.3 14.4 10.2 Delhi 4.6 13.4 12.0 7.4 Gujarat 2.7 8.6 8.8 6.1 Rajasthan 0.7 3.0 4.2 3.5 Madhya Pradesh 0.7 3.0 6.8 6.1 Maharashtra 3.4 9.9 15.6 12.2 Goa 13.7 20.0 25.5 11.8 Orissa 1.5 5.2 6.1 4.6 West Bengal 3.3 13.5 15.0 11.7 Assam 2.3 5.0.