A word renowned neonatologist, Kumar resolutes to raise the quality and service standards in maternal
and neonatal care in India and abroad

Years ago,I was working in the USA, when I read a column about a woman who had sued her obstetrician, feeling 'robbed' of her motherhood, because the Obstetrician had performed a C-Section on her which she felt was unnecessary.

A few years ago, when I was working in Australia, the debate about normal delivery vs C-section was raging hot. A woman in Sydney was very upset that people not involved in the delivery process(like law makers, politicians) are discussing this when one has to do a poll and know the pulse of the people. Because in her case, she had a normal delivery of a baby weighing 3.92 Kgs, who was severely asphyxiated and also she had perineal tear which caused her lot of morbidity in the form of incontinence and various other problems. If anyone had told her about the risks of the normal delivery ­ she would have opted for C-section.

Nearly 14 years ago, Australia went through lot of debate and many Obstetricians were ostracised for per-forming C-section for no fault of theirs. Hence, they started issuing a review article to all their prospective parents which was explaining about the benefits of a normal delivery including risks and also benefits of C-section including risks ­ which was a very balanced article and they started sharing this with the explanation that they should discuss this with all the stake holders including their midwife and come to a final decision and give consent in writing after that ­ so that the number of women accusing them will hopefully come down. This puts the onus on the prospective parents.

On a lighter note, I as a Neonatologist, always ask the parents whether their child was born by normal delivery or C-section and one of the young boys who heard his mom say C-section rather quickly jumped and said, no I am in B-section and not C-section!

Recently, we saw the Public Interest Litigation (PIL) filed by a person in Supreme Court of India and the Supreme court correctly dismissed the PIL.

There has been lot of debate about C-section and woman's rights in several countries ­ whether a woman has a right to opt for C-section or not? There has been no consensus on this as several ethical people think this has a baby's right too?

Let us look at what are the reasons behind bstetricians doing C-section and what has changed?

In the past, we had many women delivering babies by breech presentation by normal delivery but lately the risk of birth asphyxia leading to brain damage is higher in babies born by breech presentation (where the bum comes out first and head of the baby is delivered last). In view of this, most obstetricians nowadays deliver babies who are breech by C-section.

Gestational Diabetes Mellitus (GDM) is a life style disease to a great extent which was very uncommon in the past, but nowadays we have almost 25 to 30 percent pregnant women being diabetic during pregnancy

Gestational Diabetes Mellitus (GDM) is a life style disease to a great extent which was very uncommon in the past, but nowadays we have almost 25-30 per-cent pregnant women being diabetic during pregnancy ­ hence called gestational diabetes and many women with GDM though deliver normally, many deliver by C-section either because their babies have grown much bigger than their pelvis can accommodate or for some other complication.

In Vitro Fertilisation (IVF) is commonly called test tube baby. Babies conceived by IVF were not there 40 years ago. But now the number of babies conceived by IVF is increasing by the day and many parents having gone through difficult time of conceiving babies through IVF opt for C-section and many Obstetricians deliver these babiesby IVF to avoid the `unnecessary risk associated with normal delivery'thoughmedically this is not an indication for C-section.

In the olden days, we used to have Eclampsia wards in many hospitals. Even now many medical colleges and government hospitals still have Eclampsia wards, where women who have convulsion during labour/ delivery pro-cess are cared for. Nowadays, with increasing nursing and medical care ­ Eclampsia is prevented, which has lead to renewed attention on Pre Eclampsia ­ a condition which could potentially lead to Eclampsia ­ which is a dangerous condition with deleterious effects both on the baby and the mother. Many women are delivered by C-section during Pre Eclampsia to avoid Eclampsia.

Last but not the least, Muhurtham section some women want to deliver at a set date and time­ this is not peculiar when it comes to India. This is a global problem ­ growing number of women in executive positions or even working women ­ don't want the uncertainity ­ they want to deliver at a `right time' and plan their `diary'. There is discussion about the rights of women in choosing the way they want to deliver Vs what is best for them who can decide this?

I am not going to narrate the whole number of reasons why C-sections are increasing? Fair to say that I have given some glimpses into the history as to why C-sections are increasing? It is unfair to blame the hospitals or the doctors for the increasing number of C-sections. Suffice to say that the decision to deliver the babies in a particular way should be taken in con-junction with the prospective parents after having dis-cussed all the possibilities and ensure safe motherhood and baby.

India still has quite a significant maternal and neonatal mortality and places where C-sections are lower­ do they have low mortality and morbidity? Places with high C-section­ do they have high mortality and morbidity are the questions to be asked. We should have a country wide audit by using well established March of Dimes criteria for C-sections (appendix A) to see and compare various places along with morbidity and mortality data ­ before we jump in and start shouting at doctors and hospitals. We need to account for every mother's and baby's death along with morbidity data before Supreme court or Politicians can be asked to answer any question or make any policy. Are we there yet?

Lastly, one has to take into account the rights of the women and the unborn baby too, considering all these, we are in the same position as rest of the world in this debate. The final word is yet to be spoken on this.